physicians' and students' ready 
reference series. ^\ 



OBSTETRIC SYNOPSIS. 



BY 

JOHN S. STEWART, M. D., 

Demonstrator of Obstetrics, and Chief Assistant in the Gynecological Clinic of the 
Medico-Chirurgical College of Philadelphia. 



)^ 



ILLUSTRATED. 



PHILADELPHIA: 
F. A. DAVIS, Publisher. 

1888. 



( WA. 6 7888 jf 






Entered according to Act of Congress, in the year 1888, by 

F. A. DAVIS, 

In the Office of the Librarian of Congress at Washington. 

All rights reserved. 



INTRODUCTORY NOTE. 

By WILLIAM S. STEWART, A.M., M.D., 

Professor of Obstetrics and Gynecology in the Medico-Chirurgical 
College, Philadelphia. 



This little volume has been prepared under my im- 
mediate supervision and is to a great extent the result of 
accurate note-taking for a number of years of my lec- 
tures on Obstetrics, delivered before the students of the 
Medico-Chirurgical College. 

In the preparation of the Synopsis all of the leading 
works on the subject have been consulted — those of 
Play 'f air , Parvin, Lush, Galabin, and Gazeaux and 
Tarnier having been given the preference. 

In addition to the latest teachings of these Authors, 
which have been given with the amount of detail pos- 
sible and consistent with the aim and scope of the work 
and as far as they correspond with the teachings given 
my own classes from year to year, the field of recent 
journalism has been searched and some valuable sugges- 
tions and opinions thus obtained. 

The Obstetrical Nomenclature suggested by Profes- 
sor Simpson of Edinburg and adopted by the Section ot 
Obstetrics of the Ninth International Medical Congress 

cm) 



IV INTRODUCTORY NOTE. 

held in Washington, D. C, September, 1881, has not 
been strictly observed; but for the benefit of those who 
may not be familiar with it the Nomenclature, as adopted, 
has been inserted in the form of an Appendix. 

The work is specially designed to assist the under- 
graduate in acquiring a thorough knowledge of this de- 
partment, being so systematically arranged that at a 
glance he may readily inform himself on any point per- 
taining to the study. However, not being exhaustive, it 
is intended only as a stepping-stone to the many excel- 
lent but voluminous text-books, for the perusal of which 
faithful attendance on the various lectures and practical 
courses of most colleges unfortunately leaves the student 
little or no time. 

With its help in addition to the lectures it is believed 
any one can become familiar not only with the prin- 
ciples of Obstetrics, but with many of the practical points 
pertaining thereto. 

It is neither intended nor possible for this small 
work to take the place of the various text-books during 
the college career ; but it is most earnestly hoped that 
it may for the student economize time, give a compre- 
hensive view of the subject, and incite a desire for the 
knowledge of the details. 

1801 Arch Street, Philada. 



TABLE OF CONTENTS. 



PART I. 



ANATOMY. 



Abdomen 



Breasts 



Pelvis 



CHAPTER I. 



CHAPTER II. 



CHAPTER III. 



PAGE. 
1 



Bones— Articulations — Cavity— Differences in the 
Sexes— Contents— Floor. 



CHAPTER IV. 
External Genital Organs - 
Mons Veneris— Vulva— Perineum. 



. 10 



CHAPTER V. 
Internal Genital Organs 13 

Vagina— Uterus— Fallopian Tubes— Ovaries. 

O) 



VI TABLE OF CONTENTS. 



PART II. 



PHYSIOLOGY. 



CHAPTER I. 
Puberty, Ovulation, and Menstruation . . 25 



PAGE. 



CHAPTER II. 

Conception 30 

Spermatozoid — Ovule — Impregnation. 

CHAPTER III. 

Development of the Ovum 32 

In the Fallopian Tube — In the Uterus. 

CHAPTER IV. 

Fcetus . 44 

Development — Foetal Head — Foetal Circulation. 

CHAPTER V. 

Maternal Changes . 51 

In the Pelvis — In the Breasts — In the Skin — In the 

Digestive System — In the Nervous System — In the 

Circulation — In the Respiratory Organs — In the 
Cranium — In the Urine. 



TABLE OF CONTENTS. vli 



PART III. 



PREGNANCY. 



CHAPTER I. 



PAGE. 



Diagnosis of Pregnancy . . . . . 55 

Symptomatic Signs— Physical Signs— Differential Di- 
agnosis. 

CHAPTER II. 
Duration of Pregnancy 59 

CHAPTER III. 

Abnormal Pregnancy . . . . . .60 

Multiple Pregnancy — Extra -uterine Pregnancy, 

CHAPTER IY. 

Disorders of Pregnancy . . . . . 62 

Of the Digestive System — Of the Blood and Circula- 
tory System — Of the Genito-urinary System — Of the 
Nervous System — Displacements of the Uterus, 

CHAPTER Y. 

Diseases of Pregnancy 68 

Intercurrent Diseases — Pathology of the Decidua, 
Ovum, and Foetus — Abortion, Miscarriage, and Pre- 
mature Labor. 



Viii TABLE OF CONTENTS. 



PART IV. 



LABOE. 



CHAPTER I. 

PAGE. 

Phenomena of Labor 77 

Causes— Muscular Mechanism — Stages of Labor- 
Duration of Labor, 

CHAPTER II. 

Mechanism of Labor 83 

Presentations of the Head — Presentations of the Pelvis 
— Presentations of the Trunk. 

CHAPTER III. 

Management of Normal Labor . . . .92 
Examination of the Patient— First Stage of Labor — 
Second Stage of Labor — Third Stage of Labor- 
Anaesthetics and Anodynes. 

CHAPTER IV. 

Abnormal Labor 101 

Maternal Causes-— Foetal Causes. 

CHAPTER V. 

Complicated Labor 118 

Eclampsia — Placenta Praevia — Hemorrhage— Reten- 
tion of the Placenta— Inversion of the Uterus — 
Ruptures and Lacerations of the Genital Canal- 
Thrombus of the Vagina and Vulva. 



TABLE OF CONTENTS. IX 



PART V. 



THE PUEBPERAL STATE. 



CHAPTER I. 

PAGE. 

Physiology of Childbed 135 



CHAPTER II. 
Management of Childbed 138 

CHAPTER III. 

Condition and Care of the Infant . . . 140 

CHAPTER IV. 
Lactation . 143 

CHAPTER V. 

Pathology of Childbed 145 

Disorders of Lactation — Puerperal Septicaemia — Pelvic 
Cellulitis and Pelvic Peritonitis — Puerperal Throm- 
bosis and Embolism — Phlegmasia Alba Dolens — 
Puerperal Insanity. 



TABLE OF CONTENTS. 



PART VI. 



OBSTETRIC OPERATIONS. 



CHAPTER I. 

PAGE. 

Induction of Abortion and Premature Labor . 159 
Artificial Abortion — Premature Labor. 



CHAPTER II. 

Use of the Forceps . . . . . .161 

CHAPTER III. 

Version 170 

Cephalic Version — Poclalic Version. 

CHAPTER IV. 

Embryotomy 175 

Craniotomy — Decapitation — Evisceration. 

CHAPTER V 

Abdominal Section 180 

Csesarean Section — Porro's Operation — Porro-Miiller 
Operation — Laparo Elytotromy. 



PART I. 

ANATOMY. 



CHAPTER I. 

ABDOMEN. 

If two parallel lines are drawn around the body, the 

one passing over the cartilages of the ninth ribs and 

the other on a level with the highest points of the 

ilea, the abdomen is divided into three zones. By draw- 




Fig. 1.— The abdomen. 

ing from the cartilages of the eighth ribs to the 
middle of Poupart's ligaments two parallel intersecting 
lines, nine regions are outlined as follows : — - 

Right hypochondriac ; Epigastric ; Left hypochon- 
driac ; Right lumbar ; Umbilical ; Left lumbar ; Right 
iliac; Supra-pubic (Hypogastric) ; Left iliac. 

1 



OBSTETRIC SYNOPSIS. 



CHAPTER II. 
BREASTS. 

Two compound racemose {in clusters) glands, situated 
on either side of the sternum, over the pectorales majora 
muscles, and extending from the third to the sixth or 

seventh ribs. In the male, and 
in the female prior to puberty, 
they are rudimentary, but com- 
plete development is not at- 
tained until the period of lacta- 
tion following pregnancy. 

Each gland is composed of 
fifteen to twenty lobes; the 
lobes are subdivided into lo- 
bules, and these in turn are 
made np of a number of acini 
or culs-de-sac. From each of 
the latter a small canaliculus 
starts ; by the union of these 
the canals of the lobules are 
formed ; the latter anastomos- 
ing to form the galactophor- 
ous (or lactiferous) ducts, the 
canals of the lobes, which terminate at the nipple in 
small openings. 

As they approach the nipple the lactiferous ducts 
become widely dilated and form reservoirs in which the 
milk is stored ; in the nipple they again contract. 

The glands are covered with layers of connective 
and adipose tissue; the skin over them is supplied with 
sudoriparous and sebaceous glands and hair follicles. 
The nipple is situated at the summit of each breast, 




Fig. 2. — Mammary gland. 



PELVIS. 3 

ancf varies greatly in size in different women, being some- 
times depressed below the surface; at the bases of the 
papillae which are found upon it the orifices of the lacti- 
ferous ducts open. 

The areola immediately surrounds the nipple, and is 
one to two inches in diameter; it is generally more con- 
spicuous in brunettes. In addition to the sebaceous 
glands, which the skin of the areola contains, a number 
of small projections (twelve to twenty) — the glands or 
tubercles of Montgomery — are to be found upon its 
surface. These projections, which are thought by some 
to be rudimentary nipples, are generally classified as 
sebaceous glands; and although they are at all times 
visible in the majority of cases, pregnancy renders them, 
as well as the areolae, more conspicuous. 



CHAPTER III. 
PELVIS. 

1. BONES. — The bones of the pelvis (basin) are as 
follows: Ossa innominata (two), sacrum, and coccyx. 

(a) Each Os Innominatum consists of three parts, 
called ilium, ischium, and pubes; these unite in the 
acetabulum, union not being complete until after the 
eighteenth or twentieth y ear. 

(b) The Sacrum is pyramidal in shape, and origi- 
nally consists of five parts, — the anterior and posterior 
sacral foramina indicating the lines of separation. 

(c) The Coccyx is a triangular bone, formed of 
three, four, or five rudimentary vertebrae. 

2. ARTICULATIONS.— The joints of the pelvis 
are: Sacro-lumbar, sacro-iliac (two), sacro-coccygeal, 
and pubic. 



4 OBSTETRIC SYNOPSIS. 

The form of articulation is generally described as 
symphysis or amphiartlwosis, — but more recent inves- 
tigations show that in many cases (the sacro-lumbar 
joint excepted) they are true arthrodia, the opposing 
surfaces being covered with cartilage, and lined with 
synovial membranes, thus permitting a sliding motion. 

During pregnancy the ligaments become softened 
and the synovial fluid is increased, causing a wider 
separation of the bones and a greater mobility. 

3. CAVITY. — The ileo-pectineal line divides the 
cavity into an upper or false pelvis and a lower or 




Fig. 3. — The pelvis (true and false). — A A, Antero-posterior diameter; B B, 
transverse diameter; C C, two oblique diameters; 1, sacro-iliac ligament; 2, an- 
terior or lesser sacro-sciatic ligament ; 3, posterior or great sacro-sciatic ligament. 

true pelvis; the former includes all that is above the 
brim, and is chiefly for the attachment of muscles, while 
the latter contains the organs of generation, and is 
therefore of more importance to the obstetrician. 

(a) Measurements. The measurements of the pelvis 
are those of the false pelvis, called external measure- 
ments, and those of the true pelvis, called internal 
measurements. 



PELVIS. 5 

TIiq external measurements are as follows (Play- 
fair) : — 

1. Between the anterior superior iliac spines, 10 
inches. 

2. Between the middle points of the iliac crests, 10^ 
inches. 

3. Between the spinous process of the last lumbar 
vertebra and the symphysis pubis (external conjugate), 
7 inches. 



Fig. 4. — The pelvic cavity (planes and axis). — ab, Plane of the superior strait 
(brim) ; oi, plane of the inferior strait (outlet) ; c, the point where these two planes 
would meet, if prolonged ; mn, a. horizontal line ; ef, axis of brim ; gk, axis of cavity ; 
p q r s t, various points taken on the sacrum to show the plane of the cavity at each 
point. 

The internal measurements or diameters of the true 
pelvis are as follows (Play fair) : — 

Antero-posterior. Oblique. Transverse. 

1. Brim . . 4.25 inches. 4.8 inches. 5.2 inches. 

2. Cavity . 4.7 " 5.2 " 4.75 " 

3. Outlet . 5.0 " 4.2 " 

The transverse diameter being the largest at the brim, 

1* 



D OBSTETRIC SYNOPSIS. 

the oblique in the cavity, and the anteroposterior at the 
outlet. 

During life these diameters are diminished one- 
quarter to half an inch by the soft parts which cover 
and cushion the bones. 

(b) Planes. The planes of the pelvis are imaginary 
levels at any portion of its circumference. The inclina- 
tion of the plane of the pelvic brim to the horizon is 
about 60°, while that of the outlet is about 11°. 

(c) Axis. The axis of the pelvis (curve of Cams) 
is an irregular parabolic line, indicating the direction 
which the foetus takes during expulsion, and is repre- 
sented by the sum of the axes of an indefinite number 
of planes at different levels of the cavity. 

4. DIFFERENCES IN THE SEXES.— The bones of 
the female pelvis are lighter in structure and the promi- 
nences for muscular attachment are less marked ; the 
iliac bones are more spread out and the tuberosities of 
the ischia are further apart, giving greater breadth to 
the figure and causing the side-to-side movement which 
females have in walking. The depth of the symphysis 
pubis is less, and the angle of the pubic arch, the edges 
of which are everted, is greater, being 90° to 100°, in- 
stead of 60° to 75°, which it is in the male. 

The sacrum is wider, has a more regular curve, and 
its promontory does not project so far. The obturator 
foramina are larger, and, according to some authorities, 
triangular, being oval in the male. The cavit} r is wider, 
but not so deep, while the inlet is elliptical instead of 
triangular or heart-shaped. 

The joints are not so firmly united, and the synovial 
sacs are larger and more distinct, being rarely absent, as 
thev often are in males. 



PELVIS. 7 

5. CONTENTS. — The contents of the pelvis are as 
follows : Internal genital organs and their appendages, 
together with the rectum and bladder, all of which are 
invested by peritoneum; iliacus and psose muscles on 
either side of the upper or false pelvis, cushioning the 
bones and lessening the diameter of the inlet ; pyriformes 
and obturatores interni, small portions of each being 
within the cavity of the pelvis, and supposed by some 
to assist in the rotation of the foetal head; crural and 
obturator nerves (from the lumbar plexus), the sacral 
plexus, with its branch, the sacro-sciatic, and the pelvic 
ganglia of the sympathetic system ; the following arte- 
ries, ovarian and middle sacral (from the aorta), hemor- 
rhoidal, external iliac, internal iliac and its branches 
the vesical, uterine, vaginal, obturator, internal pudic, 
and sciatic. These contents are connected by cellular 
tissue and the pelvic fascia. 

6. FLOOR. — The outlet of the pelvis is closed by a 
muscular floor composed of two pairs of muscles, the 
levator ani and coccygeus on either side; between them, 
at their juncture in the median line, are the openings for 
the urethra, vagina, and rectum. 

The levator ani arises anteriorly from the pubic 
ramus, posteriorly from the ischial spine, and between 
these points from the pelvic fascia ; its fibres pass down- 
ward and inward, and are inserted at the base of the 
bladder and tip of the coccyx, uniting with the muscle 
of the opposite side in the median line where they are 
attached to the walls of the vagina and rectum. 

The coccygeus arises from the spine of the ischium, 
and is attached to the border of the coccyx and the 
lower part of the side of the sacrum. 



8 OBSTETRIC SYNOPSIS. 

A line drawn across this region in front of the tuber- 
osities of the ischia, divides the pelvic floor into two 
triangles, an anterior or urethral, and a posterior or 
rectal triangle. 

(a) Urethral triangle. In the anterior or urethral 
triangle are the following structures : — 

(1) E rector es clitoridis (two), arising from the inner 
side of each ischial tuberosity, and meeting in front of 
the pubic joint to form the body of the clitoris. 




Fig. 5. — The pelvic floor (triangles). — A, Anus; B, bulbi-vaginae; C, coccyx; 
G, gluteus maximus muscle; L, great sacro-sciatic ligament; P, perineal body; U, 
urethra; V, vagina; g, vulvo-vaginal gland; 1, clitoris ; 2, its suspensory ligament ; 
3, crura clitoridis ; 4, erector clitoridis muscle ; 5, bulbo-cavernosus muscle ; 7, trans- 
versa perinei muscle ; 8, sphincter ani ; 9 and 10, levator ani muscle ; 11, coccygeus 
muscle ; 12, obturator externus muscle. 

(2) Bulbo-cavernosi (two), muscular slips which spring 
from the perineal body, pass around the vaginal orifice 
and divide into three portions which terminate as fol- 



N PELVIS. 9 

lows : one to the under surface of the corpus caverno- 
sum of clitoris, another to the posterior surface of bulb, 
the third blending with the mucous membrane of the 
vestibule. 

(3) Bulbi-vaginse (two) (corpora-cavernosa urethrae), 
small masses of erectile tissue on each side of the vagina 
and parti}' covered by its sphincter. They blend ante- 
riorly, forming the pars intermedia which unites the 
clitoris and its glans. 

(4) Vulvovaginal glands (two) (g Ian ds of Bartholin), 
analogous to Cowper's glands in the male, and lying at 
each side of the vaginal orifice just posterior to the 
bulb. Each gland is supplied with a duct which opens 
in front of the attached edge of the hymen, or at the 
base of one of the carunculae myrtiformes. 

(b) Rectal triangle. In the posterior or rectal tri- 
angle is situated the sphincter ani muscle, beneath which 
lie portions of the levatores ani and coccygei. 

The transversus perinei muscles (two), arising from 
the ischial tuberosities on each side unite in the median 
line where they are inserted into the perineal body ; 
they divide the pelvic floor into its two triangles and 
form the bases of each. 

The perineal body is a triangular mass of connective 
tissue lying between the lower portions of the vagina 
and rectum. Its use is as a support; to it the 'following 
muscles are attached: sphincter ani, levator ani, trans- 
versus perinei, and bulbo-cavernosi. 



10 



OBSTETRIC SYNOPSIS. 



CHAPTER IY. 

EXTERNAL GENITAL ORGANS. 

The external genital organs Qpudenduni) consist of 
the following parts: Jlons veneris, vulva, and perineum. 





Fig. 6. — External genital organs. — 1, Labia majora; 2, fourchette; 3, labia- 
minora ; 4, clitoris ; 5, meatus urinarius ; 6, vestibule ; 7, orifice of vagina ; 8, hymen ; 
9, orifice of duct of vulvo-vaginal gland ; 10, anterior commissure ; 11, anus. 

I. MONS VENERIS.— An eminence at the base of the 
hypogastric region; it is composed of integument which 
contains a large number of hair follicles and sebaceous 
glands, connective and adipose tissue. The hair makes 
its appearance at puberty, its probable use being to pro- 



EXTERNAL GENITAL ORGANS. 11 

tect the vulva from irritation produced by profuse per- 
spiration; 

2. VULVA. — A general term, comprising all the 
parts between the mons veneris and perineum, which 
are as follows : — 

(a) Labia majora (externa). Two folds of skin ex- 
tending from beneath the mons veneris to the anterior 
part of the perineum; they form by their union in front 
the anterior commissure, and by their union behind the 
posterior commissure which is generally described as 
the fourchette. They contain sebaceous glands, and ex- 
ternally are covered with hair ; the internal surfaces are 
smooth, and resemble mucous membrane. 

In the virgin the labia are firm and in apposition, but 
after labor or repeated coitus, and in old age, they become 
separated from relaxation. 

(b) Labia minora (interna) or nymphae. Two smaller 
folds commencing near the middle of each external lip, 
and converging near the clitoris where they bifurcate, the 
lower division forming the frsenum or suspensory liga- 
ment of the clitoris and the upper its prepuce. They 
are sometimes described as meeting posteriorly and 
forming the fourchette. 

Although partly covered with epithelium, and in 
appearance like a mucous surface, they are probably 
delicate skin (or muco-cutaneous). Beneath the surface 
are a large number of sebaceous glands. 

In the virgin they are normally concealed; after 
labor, repeated coitus, or in old age they are exposed 
on account of separation of the labia majora, but con- 
tinued irritation will sometimes cause hypertrophy and 
protrusion. 



12 OBSTETRIC SYNOPSIS. 

(c) Clitoris. A small elongated body analogous to 
the penis of the male. It is situated beneath the ante- 
rior commissure, and consists of two crura, a body, and 
a glans. 

(d) Vestibule. A triangular mucous surface, the 
vaginal orifice forming its base and the nymphae its 
sides, while the clitoris occupies the apex. 

(e) Meatus urinarius. The urethral orifice is situated 
near the base of the vestibule ; the irregular elevations 
surrounding it, and the projections at its lower margin 
are guides for the introduction of the catheter. 

(/) Vaginal orifice. In virgins a circular opening, 
in others a transverse fissure. 

(g) Hymen. A thin fold of mucous membrane which 
in virgins and most nulliparae partly or entirely closes 
the vaginal orifice. Its shape is usually crescentic, 
but may be annular, fimbriated, cribriform, or imper- 
forate. 

(h) Carunculae myrtiformes. Fleshy tubercles, the 
remains of the ruptured hymen. It has been affirmed 
by some that they are seldom, if ever, found except after 
labor. When inflamed they may be mistaken for syphi- 
litic vegetatious. 

(i) Fossa navicularis. A depression between the 
hymen and the fourchette ; as the inner surface of the 
fourchette is normally in contact with the hymen, the 
fossa is concealed, but can be exposed by depressing the 
fourchette. 

The glands of the vulva are of three varieties : sudori- 
parous, sebaceous, and muciparous glands or follicles. 

Sudoriparous glands are found in the external parts, 
chiefly in the labia majora. 



INTERNAL GENITAL ORGANS. 13 

Sebaceous glands are very numerous in both labia 
(majora and minora), and secrete an odorous fluid which 
may become offensive in untidy persons. 

Muciparous glands are about the vaginal orifice, the 
vulvo-vaginal (glands of Bartholin) being the largest of 
this variety. 

3. PERINEUM. — The space between the posterior 
commissure and the anus; beneath the integument is 
the perineal body. 

The blood-supply of the pudendum is derived from 
the pudic and epigastric arteries. 

The nerves are branches of the external pudic and 
of the lumbar plexus. 



CHAPTER V. 

INTERNAL GENITAL ORGANS. 

The internal genital organs consist of the following 
parts : Vagina, uterus, Fallopian tubes, ovaries. 

■ I. VAGINA. — A curved canal lying in the axis of the 
pelvis and connecting the uterus with the external gene- 
rative tract. Its length varies greatly, and is from two 
and a half to four inches, the posterior wall being about 
half an inch longer than the anterior. The walls being 
in apposition make it a transverse slit, which, as it ap- 
proaches the uterus, becomes more capacious and termi- 
nates in the anterior and posterior culs-de-sac. 

In front of it are the bladder and urethra ; behind, 
the rectum and perineal body, all the parts being united 
by loose connective tissue. At its upper and posterior 
border it is separated from the rectum by the peritoneal 
pouch called Douglas 1 cul-de-sac. 



14 OBSTETRIC SYNOPSIS. 

The vagina consists of three layers, an external of 
connective tissue, a middle or muscular, and an internal 
or mucous. 

The external layer, being connective tissue, supports 
the vagina by attaching it to the surrounding parts. 

The muscular layer is of the unstriped variety and 
consists of longitudinal, oblique, and circular fibres, 
which are inserted below in the ischio-pubic rami, being 
continuous above with the middle muscular layer of the 




Fig. 7. — Internal genital organs — U, Uterus (anterior surface) ,' O O', ovaries ; 
P P', fimbriae; C, intra- vaginal portion of cervix; R R', round ligaments; V V, 
vagina laid open; L L', broad ligaments; M, ovarian ligament; T T', Fallopian 
tubes. 

uterus. The vaginal columns are thickened ridges in 
the lower portions of the anterior and posterior walls, 
those in the anterior wall being the more prominent. 

The mucous layer is covered with cylindrical and 
pavement epithelium and numerous vascular papillae ; it 
contains a few mucous glands, the secretion of which is 
acid. The mucous membrane, especially at the lower 



INTERNAL GENITAL ORGANS. 



15 



part of the anterior wall, is thrown into transverse folds 
or elevations called rugae; they are more distinct in the 
virgin, and increase the sensibility of the surface. 

The vaginal blood supply is derived from the vaginal, 
uterine, vesical, and pudic arteries, branches of the in- 
ternal iliacs. 

The veins are valveless and plexiform. 

The nerves are from the hypogastric plexus. 

2. UTERUS. — The organ of gestation and parturi- 
tion ; it is pear-shaped, but flattened from before back- 
ward, and situated in the true pelvis with the fundus 
just below the brim. In front is the bladder, and 




e 

Fig. 8. — Section of internal genital organs (cavity of uterus and Fallopian 
tubes). — A, Fundus; B, cavity of body of the uterus; O, cavity of cervix; D D, 
canals of Fallopian tubes cut open; E E, fimbriated extremities laid open ; F F, 
ovaries, one-half of each removed so as to bring into view several Graafian follicles ; 
G, cavity of vagina; H H, ovarian ligaments; G G, round ligaments. 

behind the rectum, each of which, by its fullness or 
emptiness, affects the situation of the uterus. 

Length. 

In the virgin 2% inches. 

In the multipara 3 " 

At full term of gestation . . . . 12 to 14 " 

Weight. 

In the virgin . 1 ounce. 

In the multipara \y 2 ounces. 

At full term of gestation . . . . 24 to 28 " 



16 OBSTETRIC SYNOPSIS. 

The size and weight of the uterus are slightly in- 
creased during each menstrual period. 

(a) Regions. The uterus consists of a fundus, 
body, and cervix or neck. 

The fundus is the pbrtion above the insertions of 
the Fallopian tubes. 

The body is the portion between the Fallopian tubes 
and the constriction near the middle of the organ which 
corresponds with the internal os. 

The cervix or neck is the remaining portion which 
is limited above by- the internal os and below b}^ the 
external os. The intra-vaginal portion of the cervix 
varies greatly in length and in shape, but the anterior 
lip is usually more prominent than the posterior. 

(b) Cavity. The cavit} T of the uterus is small com- 
pared with the size of the organ, and consists of two 
compartments, an upper, within the body, and a lower, 
within the cervix. 

The cavity of the body communicates at each side 
with the Fallopian tubes and below is continuous with 
the cavity of the cervix. In the virgin or nullipara it 
is triangular with its opposing convex surfaces in appo- 
sition ; in the multipara it is larger and more ovoid. 

The cavity of the cervix is fusiform, and larger in 
the nullipara than it is after labor. 

(c) Structure. The uterus consists of three la}^ers, 
an external serous or peritoneal, a middle or muscular, 
and an internal or mucous. 

The serous coat (layer) is reflected from the bladder 
and covers the upper three-fourths of the anterior sur- 
face, extending as far down as the internal os. On the 
posterior surface it descends as far as the insertion of 
the vagina, on which it extends for a short distance and 



INTERNAL GENITAL ORGANS. 17 

is then reflected upon the rectum, forming the floor of 
Douglas* cul-de-sac. In front and behind it is very ad- 
herent to the uterine walls, but laterally the attachments 
are quite loose. Most of the uterine ligaments are folds 
of peritoneum. 

The muscular layer is of the unstriped variety, and 
consists of longitudinal, irregular, and circular fibres. 

The external or longitudinal fibres are chiefly upon 
the posterior wall, at the upper part of which they run 
transversely, and are continuous with the muscular 
tissues of the Fallopian tubes, broad, round, ovarian, and 
sacro-uterine ligaments. 

The middle fibres form the bulk of the muscular 
tissue of the uterus ; running upward, they decussate 
and unite with each other so that the superficial become 
the deep, and vice versa. The}' encircle the large veins 
and check hemorrhage by their contractions. 

The internal or circular fibres consist of rings which 
begin around the openings of the Fallopian tubes ; the 
circles become wider until they meet on the body of the 
uterus, extending as far as the internal os, where they 
form a sphincter. 

The muscular tissue of the cervix is formed of the 
external and internal fibres. 

The mucous layer is of two varieties, that of the body 
and that of the cervix. The mucous membrane of the 
body is a pale pink, and covered with cylindrical ciliated 
epithelium and glandular secretion of alkaline reaction. 

During menstruation it enlarges to two or three times 
the ordinary size, and loses its layer of epithelium. The 
entire surface is perforated by the ducts of the utricular 
glands, which are very numerous. 

2* 



18 OBSTETRTC SYNOPSIS. 

The mucous membrane of the cervix is firmer and 
more transparent, and is covered with cylindrical and 
pavement epithelium. The glands, which here also are 
very numerous, are racemose, not tubular as are those 
of the body. 

During pregnancy the cervical canal is frequently 
filled with a plug of alkaline mucus which these glands 
secrete. 

The ovula Nabothii are retention cysts caused by ob- 
struction of the excretoiy ducts and accumulation of 
the secretions. 

The arbor vitse consists of longitudinal ridges in the 
anterior and posterior walls from which branches are 
given off in an oblique direction ; this appearance is 
most distinct in the virgin. 

(d) Differences in the virgin and multipara. Thein'r- 
gin or nulliparous uterus is smaller and more compact ; 
the fundus is more flattened ; the cervix is longer, espe- 
cially the intra-vaginal portion, which is regular in out- 
line and more or less conical ; the external os is a short 
transverse slit or small rounded opening, its edges being, 
in the multipara, irregular and fissured with an orifice 
sufficiently patulous to admit the tip of the finger. 

In addition to the differences before mentioned, in 
the shape and size of the cavities of the body and cervix, 
there is also a difference in their relative sizes ; the cavity 
of the cervix, which in the virgin is slightly the larger, 
becoming after labor the smaller of the two cavities. 
In the virgin the arbor vitse is more distinct. 

(e) Anomalies. The most common anomaly is a 
double or partially double uterus; the vagina ma}' be 
double also, each one leading to a separate uterus, and, 
in some rare cases, to a single one. 



INTERNAL GENITAL ORGANS. 19 

In such cases pregnancy can occur in one or both of 
the cavities ; in the latter instance there may be con- 
siderable development of one ovum before the second 
impregnation occurs. A knowledge of the development 
of the uterus in foetal life explains the occurrence of 
these anomalies. 

During a part of this period the Wolffian bodies, a 
series of fine tubes emptying into a common duct and 
acting as temporary kidneys, are situated on either side 
of the vertebral column. From them and along their 
external borders two hollow canals are formed; the canals 
of Midler, which empty into the same common outlet. 
The Wolffian bodies soon atrophy, the parovarium, a 
series of fine tubes arranged in pyramidal form in the 
substance of each broad ligament, being the only re- 
mains. The canals of Midler gradually approach each 
other, and their lower portions lying side-by-side in close 
apposition become, by the absorption of the partition, a 
single organ with a single cavity — the uterus. 

The canals remain widely separated, and eventually 
become the Fallopian tubes. Any interference in the 
progress of this development may prevent absorption of 
the partition, and thus produce one or more of the anom- 
alies mentioned. 

(/) Ligaments. The ligaments which support the 
uterus are eight — two broad, two round, two vesico- 
uterine, and two utero-sacral. 

The broad ligaments are double folds of peritoneum 
which extend from the sides of the uterus to the sacro-iliac 
joints; passing over its anterior and posterior surfaces 
they meet in the median line and divide the pelvic cavity 
into two unequal parts. Upon the upper border of each 



20 OBSTETRIC SYNOPSIS. 

ligament are three folds or wings — an anterior inclosing 
the round ligament, a middle inclosing the Fallopian 
tube, and a posterior which incloses the ovary and its 
ligament. The broad ligaments contain muscular tissue 
derived from the external or longitudinal uterine fibres, 
between their folds are the uterine and ovarian vessels, 
tymphatics, and nerves. 

The round ligaments are muscular cords enveloped 
by the anterior wings of the broad ligaments; they 
extend from the upper borders of the uterus to the 
inguinal canals through w T hich they pass, and blend 
with the cellular tissue of the labia majora. By their 
contractions during labor and sexual intercourse the 
upper portion of the uterus is drawn forward. 

The vesico-uterine ligaments are folds of peritoneum 
connecting the body of the uterus with the fundus of the 
bladder. 

The idero-sacral ligaments are folds of peritoneum 
connecting the posterior surface of the uterus w T ith the 
sacrum, thereby affording considerable support. In its 
normal position the uterus is slightly anteverted, but can 
be readily displaced in any direction. During pregnancy 
all of the ligaments are put upon the stretch, but return 
to their natural size shortly after delivery. 

The blood-supply of the uterus is derived from the 
uterine and ovarian arteries and from branches of the 
epigastrics contained within the round ligaments. 

The veins are very large, valveless, and anastomose 
freely ; during pregnancy they increase in size and are 
called sinuses ; passing out of the uterus at its sides, 
and uniting with the ovarian and vaginal veins, they 
form between the folds of the broad ligaments the 
" pampiniform plexus. " 



INTERNAL GENITAL ORGANS. 21 

The lymphatics arise from the large lymph spaces so 
numerous at the base of the mucous membrane of the 
uterus. They unite with the vessels arising from the 
muscular and peritoneal layers and pass out between the 
folds of the broad ligaments. 

The nerves are derived mainly from the sympathetic 
ganglia ; the sacral nerves from the eerebro-spinal system 
send numerous branches to the cervix, a few of which 
are also distributed to the body of the uterus. 

3. FALLOPIAN TUBES.— The excretory ducts of 
the ovaries ; they consist of two tubes contained in the 
middle wings of the broad ligaments, and pass from the 
upper angles of the uterus for a distance of three to five 
inches, terminating in expanded extremities which are 
surrounded by fringe-like processes — the fimbriae (ten- 
tacles). One of the fimbriae larger than the rest is 
attached to the surface of the ovary (tubo-ovarian 
ligament). 

The diameter of the tube increases from its uterine 
end, where it measures on e-twent} T -fifth to one-fifteenth 
of an inch, to the fimbriated extremity, where it is 
widely expanded. Each tube consists of three layers — - 
an external or peritoneal, a middle or muscular, and an 
internal or mucous. 

The peritoneal layer extends as far as the fimbriated 
extremit} 7 , where it is in contact with the mucous mem- 
brane, the only instance in the body of such a union. 

The muscular layer consists of longitudinal and cir- 
cular fibres continuous with those of the uterine walls. 

The mucous layer is thrown into a number of longi- 
tudinal folds and is covered with ciliated epithelium, the 
action of the cilia being toward the uterus. 



22 OBSTETRIC SYNOPSIS. 

4. OVARIES. — Two bodies analogous to the testicles 
of the male ; they are situated on either side of the 
uterus in the posterior wings of the broad ligaments, 
and, except during pregnancy or when displaced from 
other causes, lie just below the plane of the pelvic brim. 
They are attached to the uterus by the uteroovarian 
ligaments, and to the tubes by the large fimbriae, called 
tubo-ovarian ligaments. In shape they are ovoid, flat- 
tened from before backward and on the lower surface, 
but convex above. The size varies greatly, as, during 
menstruation and pregnancy, they become nearly twice 
as large as the}- are at other times. The average meas- 
urements are, length one and a quarter to one and a half 
inches, depth one-half inch, thickness one-half to three- 
quarters of an inch. The average weight is one and a 
half to two drachms. 

Before puberty the surfaces are smooth, but after 
ovulation has commenced the}^ become uneven from the 
cicatrices of ruptured ovisacs ; in old age they are 
wrinkled and atrophied. 

The ovaries are covered with a layer of cylindrical 
epithelium derived from the peritoneum ; beneath this is 
a fibrous envelope called tunica albuginea, the existence 
of which as a separate structure has been disputed, being, 
it is claimed, the outer part of the ovarian tissue. 

The tissue proper (stroma) consists of an external or 
cortical, and an internal, bulbous or medullary portion, 
the former containing the ovisacs while the latter is 
vascular in structure and forms the bulk of the stroma. 

The blood supply of the ovary is derived from the 
ovarian and uterine arteries, the numerous branches of 
which have entrance at its lower border. Passing to the 



INTERNAL GENITAL ORGANS. 



23 



medulla they send small branches to the cortical portion 
and to the walls of the ovisacs which have commenced 
to enlarge. 

The veins emerge at its lower border ; here they are 
very large and varicose in appearance and form an erec- 
tile plexus, the bulb of the ovary. 

The lymphatics are large and follow the course of the 
other vessels. 

The nerves are from the ovarian plexus of the sym- 
pathetic. 




Fig. 9. — Section of two Graafian follicles of different sizes.— fi, Peritoneal or 
quasi-peritoneal covering ; st, ovarian stroma (cortical portion) ; ov, the two outer 
layers of the ovisac called tunica fibrosa and tunica propria ; mg, membrana granu- 
losa. Around the ovum the accumulated cells are seen forming the discus proligerus, 
(Enlarged about eight diameters.) 

(a) Ovisacs. Each ovary it is estimated contains 
from 30,000 to 300,000 ovisacs or Graafian follicles, 
which, in their undeveloped state, measure y^ff of an 
inch in diameter. At puberty fifteen to twenty of them, 
of var} T ing sizes, become visible to the unaided eye, and 
some maturing more rapidly than others approach the 
surface of the ovary and cause projections upon it. One 
of these, becoming larger than the rest and having caused 
a projection measuring at its base about one-half inch in 
diameter, bursts and permits the escape of the ovule. 



24 OBSTETRIC SYNOPSIS. 

The ovisac from without inward is composed of the 
following layers : — 

(1) Tunica fibrosa. 

(2) Tunica propria. 

(3) Membrana granulosa, a layer of round nucleated 
cells which line the wall of the follicular cavity. 

(4) Discus proligerus, an accumulation of the cells 
of the membrana granulosa around the ovule. 

(5) Liquor folliculi, a transparent fluid formed from 
the cells lining the follicular cavity. 

(b) Ovules. The ovules are developed from the germ 
epithelium which covers the surfaces of the ovaries. 
During foetal life these cells become embedded in the 
ovarian stroma by a dipping process ; subsequently each 
one is surrounded by a growth of delicate connective 
tissue from the ovarian stroma, the ovisac. 

The ovule is attached to the inner surface of the 
ovisac, and is surrounded by a layer of cells distinct 
.from the discus proligerus in which it lies. At the 
time of its escape from the ovisac the ovule measures 
T Jo of an inch in diameter. 

From without inward it is composed of the following 
laj' ers and parts : — 

(1) Zona pellucida or vitelline membrane. 

(2) Vitellus or yelk. 

(3) Germinal vesicle {nucleus). 

(4) Germinal spot {nucleolus). 



PART II. 

PHYSIOLOGY. 



CHAPTER I. 
PUBERTY, OVULATION, AND MENSTRUATION. 

1. PUBERTY. — The period at which reproduction is 
first possible. In the female it occurs earlier than in the 
male, and the accompanying changes are more marked. 
The whole body enlarges, especially the pelvis and 
breasts, the figure becomes more symmetrical, and the 
carriage more graceful. The external genitals are de- 
veloped, and covered externally by a growth of hair. 
The demeanor is changed to one of dignity, modesty, 
and reserve. In short, the girl becomes a woman. 

The most important of all the changes are those which 
affect the internal genital organs, but these changes can 
be studied in connection with ovulation and menstruation. 

2. OVULATION. — A process which is repeated at 
longer or shorter intervals between puberty and the 
menopause, except during gestation, when it is normally 
suspended. At the age of puberty the ovaries increase 
in size and enter upon the discharge of their special 
function. Before this period the ovisacs undergo no 
change of size; but now, stimulated by the new impulse 
given the entire s}^stem, and especially the generative 
tract, fifteen to twenty of them, as has been mentioned, 
commence to grow and gradually increase in size until 

3 (25) 



26 • OBSTETRIC SYNOPSIS. 

they form projections upon the ovarian surfaces, the 
great expansion of their walls being due to an increase 
in the quantity of the liquor folliculi. When the pres- 
sure from within has become too great for the walls, or 
when there is a special excitation produced by sexual 
intercourse, the sac bursts and its contents escape. 

That ovulation is strictly periodical, and that it 
occurs only in connection with menstruation, is not 
generally believed. Some authorities maintain that in- 
creased or diminished blood supply regulates the rapid 
or slow maturing and rupture of the follicle ; others, 
that the maturing of the follicle is the cause of the 
periodical congestion and hemorrhage. Cases are on 
record in which ovulation has occurred without men- 
struation, and vice versa. 

After rupture the walls of the follicle collapse and 
its cavity becomes filled with a small quantity of blood 
or lymph ; surrounding this central clot is an oval con- 
voluted ring, the convolutions being composed of the 
hypertrophied cells of the membrana granulosa ; this is 
called corjms luteum (false). The folds increase in size 
until they fill the follicular cavity and form a whitish 
stellate cicatrix which generally disappears in less than 
forty days from the period of rupture and leaves but a 
slight depression. 

When impregnation of the discharged ovule has 
occurred the ovary is stimulated to increased growth, 
and the corpus luteum (true), instead of contracting 
and disappearing as described, continues to grow until 
the third or fourth month of pregnancy. At this period 
and sometimes earlier it begins to atrophy, this process 
being completed in from one to two months after delivery. 



PUBERTY, OVULATION, AND MENSTRUATION. 27 

As a sign of pregnancy the corpus luteum (yellow 
body) is not altogether reliable. 

3. MENSTRUATION (catamenia, etc.).— A periodi- 
cal discharge of blood from the mucous membrane of 
the uterus, normally occurring every twenty-eight days, 
but generally suspended during pregnancy and lacta- 
tion. 

At the age of puberty when ovulation commences 
menstruation makes its first appearance, the average age 
at which it is established being from thirteen to fifteen 
years. At first it does not recur with any regularity, 
and is accompanied by pains in the back and breasts 
and a sense of general discomfort, while the amount of 
the discharge is usually slight. 

Its early or late establishment is influenced by 
climate, race, and surroundings. 

(a) Climate. Girls brought up in warm or tropical 
climates menstruate earlier than those who have lived 
in colder ones. 

(6) Race. The descendants of natives of warm 
climates habitually menstruate earlier, even after re- 
moval from such influences. 

(e) Surroundings. Children of a highly developed 
nervous organization, the result of luxury or premature 
stimulation of the mental faculties, menstruate earlier 
than those who are country-bred or of the poorer 
classes. 

The menstrual fluid consists of red and white blood 
globules, mucus, epithelium from the vagina and uterus, 
and secretions from the genital glands. Normally it is 
alkaline in reaction and without coagula, either on ac- 
count of the admixture of the glandular secretions or 



28 OBSTETRIC SYNOPSIS. 

from defibrination due to the slowness with which it 
flows from the uterus. The peculiar odor is due either 
to long retention of the fluid in the uterus and vagina 
or to the admixture of the secretions. 

Menstruation continues from three to five days in 
the majority of healthy women, and the quantity of blood 
discharged is about from two to three ounces, both dura- 
tion and quantity varying, even in health, according to 
the climate, diet, and surroundings. 

Apart from pregnancy a temporary or premature 
cessation of menstruation may be caused by exposure to 
cold, mental impressions or emotions, change of resi- 
dence and mode of living, or by anaemia and the wasting 
diseases. 

Between the ages of forty and fifty years menstrual 
life usually terminates, although its cessation may occur 
earlier or later. This period is called the menopause, 
and may be accompanied by various nervous disorders ; 
as a rule, when menstruation has commenced at an early 
age, the menopause is later, and vice versa. 

Preceding each menstruation there is an increased 
flow of blood to the pelvic organs, causing a congestion 
and temporary hypertrophy of some of them. 

The ovaries and uterus are specially affected, the 
latter increases in size about one-fourth, its mucous mem- 
brane swells, and the glands pour out an abundant secre- 
tion which is finally followed by a flow of blood. The 
same determination of blood which effects such uterine 
changes is said to bring about the rapid maturing and 
rupture of one or more of the ovisacs. 

Although ovulation is not strictly periodical, occur- 
ring as it sometimes does between the intervals of men- 



PUBERTY, OVULATION, AND MENSTRUATION. 29 

struation or when menstruation is entirely absent, prob- 
ably it almost always occurs during some part of the 
menstrual period, or, as some have thought, just preced- 
ing its appearance. 

Menstruation has been described as a " diminutive 
of pregnancy," " a periodical abortion," u a sign of dis- 
appointed impregnation." 

Yarious causes for this periodical congestion and 
subsequent discharge of blood have been enumerated ; 
among them are the following : The elimination of 
poisonous materials from the blood ; the removal of 
superfluous blood which at other times goes to the 
nourishment of the growing foetus; reflex irritation from 
pressure of the growing ovisac upon the ovarian nerves, 
or, it may be to accustom the female to loss of blood 
that she may with safety endure the greater loss in 
labor. 

It is thought by some to be the result of glandular 
function, the menstrual organ being the endometrium ; 
according to this theory impregnation of the ovule may 
occur at any time, but its retention in the uterus and 
the establishment of pregnancy will not ensue unless 
the removal of the epithelium of the mucous membrane 
has occurred just before its entrance. 

An entirely satisfactory cause has not been discov- 
ered, nor is it known just when impregnation of the 
ovule is most likely to occur, — whether before or after 
the menstrual period ; but that the few days immediately 
following are the most favorable is generally believed. 



30 OBSTETRIC SYNOPSIS. 

CHAPTER II. 

CONCEPTION. 

The union of the male and female elements of gene- 
ration (spermatozoid and ovule). 

1. SPERMATOZOID.— The male element, a small 
body 5J0 of an inch in length, having an oval head to 
which is attached a delicate body and tail. Thev are 
found in healthy semen in vast numbers, and are formed 
in the sperm cells which are derived from the tubuli- 
seminiferi of the testicle. 

The nuclei of these cells proliferate and b}' their 
subdivisions form the heads of the spermatozoids, their 
bodies being made up of the protoplasm of the cells ; 
it is by the decomposition of the substance in which the 
heads are embedded that they are liberated. 

When brought in contact with cold or acid solutions 
they soon lose their vitality ; in the acid secretions of 
the vagina the}^ remain active but a few hours, but in 
the uterus or Fallopian tubes where the secretions are 
alkaline their movements may continue for several days. 

The ascension of the spermatozoids is clue to their 
own power of motion, which may be assisted by a sort 
of sucking movement of the uterus during coition, by 
peristaltic action of the uterus and Fallopian tubes, by 
capillary action, or by the movements of the ciliated 
epithelium. 

2. OVULE. — The female element of generation. 
When the ovisac ruptures the ovule generally escapes 
from it and rests for a short time upon the surface of the 
ovary. 

If the ovule does not fall into the abdominal cavitv 



CONCEPTION. 31 

it is generally grasped by the fimbriated extremity of 
the Fallopian tube; some, however, claim that a groove 
in the upper surface of the tubo-ovarian ligament guides 
it to the entrance of the tube. 

Having entered the tube, it is carried toward the 
uterus by the motions of the cilia and by the peristaltic 
action of the tube itself; during this passage, whether 
impregnation has or has not occurred, the following 
changes are said to take place : — 

(a) An external coating of albumen is formed. This 
albuminous coating has been seen upon the ovules of 
most of the lower animals, and although never observed 
upon the human ovule, is believed to exist and to form 
with the zona pellucida the primitive chorion which con- 
tributes to the nourishment of the ovule. 

(b) The germinal vesicle moves toward the periphery 
of the ovule; there it sends out a process, the polar 
globule, which may subdivide once or twice. 

(c) The yelk contracts and becomes more solid ; by 
its retraction a cavity is formed between the yelk and 
the zona pellucida — the respiratory chamber, which is 
sometimes filled with a liquid. 

If impregnation of the ovule has not occurred 
no further changes take place, the ovule disintegrates, 
and is lost in the discharges from the genital canal. 

3. IMPREGNATION.— Whether one or a number of 
spermatozoids gain entrance to the ovule is still a dis- 
puted point ; by some authorities it is claimed that the 
entrance of more than one will result in the production 
of a monstrosity. 

The mode of entrance is also unknown ; in the 
ovules of certain fish and of a few of the lower animals 



32 OBSTETRIC SYNOPSIS. 

minute openings in the zona pellucida have been dis- 
covered, but in this respect they seem to differ from the 
human ovules. 

The union of the two elements of generation in the 
majority of cases occurs either on the surface of the 
ovary or in the outer portion of the Fallopian tube, and 
not in the cavity of the uterus (with rare exceptions) as 
was formerly believed on account of the albuminous 
coating which, as soon as formed, interferes with the 
entrance of the spermatozoids. 

The entrance having been effected there is at once a 
fusion of the male and female nuclei; but how this 
brings about the important changes which follow is still 
a mystery. 

CHAPTER III. 
DEVELOPMENT OF THE OVUM. 

I. IN THE FALLOPIAN TUBE.— The length of time 
occupied by the ovum in its passage through the tube is 
supposed to be ten to twelve days. This fact and the 
knowledge of most of the changes which occur during 
this period have been obtained chiefly by studying the 
process in the lower animals, an opportunity for this 
study in the human being seldom afforded. The changes 
which occur in it after impregnation are as follows : — 

(a) Formation of the vitelline nucleus. A clear spot 
which appears in the centre of the yelk ; it is probably 
the result of the union of the male and female nuclei. 

(6) Segmentation of the yelk. A process of division 
which commences in the vitelline nucleus almost imme- 
diately after its appearance and extends to the yelk 



DEVELOPMENT OF THE OVUM. 



33 



causing a division of it into halves ; subdivision after 
subdivision takes place until the yelk has been separated 
into a number of minute spheres, each of which contains 
a portion of the vitelline nucleus; this mass, from its 
supposed resemblance to a mulberry, has been called the 
" muriform body." 

(c) Formation of the blastoderm. The cells of the 
muriform body which, by the formation of a fluid in 
the centre of the mass are pressed to the surface of the 




Fig. 10. — Segmentation of the yelk. 

ovum, spread out and flattened beneath the zona pellu- 
cida. When the blastodermic membrane, as it is called, 
is completely formed the ovum has reached the uterus. 

2. IN THE UTERUS.— While the ovum is in the 
Fallopian tube the uterine mucous membrane undergoes 
various changes for its reception and retention. The 
changes are similar to those which occur just before 
each menstruation ; the mucous membrane is thickened, 
softened, and more vascular, but instead of degenerat- 



34 



OBSTETRIC SYNOPSIS. 



ing or undergoing atropy it continues to grow and 
becomes what is known as the "decidua." 

The decidua consists of three portions : Decidua 
vera, decidua serotina, decidua reflexa. 




Fig. 11. — Formation of decidua (first stage). 

Decidua vera. Originally, all of the changed uterine 
mucous membrane; after the attachment of the ovum it 
is that portion which lines the remainder of the cavity. 

Decidua serotina. That part of the decidua vera 
upon which the ovum rests ; it afterward enters into the 
formation of the placenta. 

c 




Fig. 12. — Formation of decidua (completed). — a, Decidua reflexa; 3, decidua vera; 

c, decidua serotina. 

Decidua reflexa. A growth of the decidua vera 
around the ovum, covering its free surface. Before the 
third month of pregnancy the decidua reflexa and de- 
cidua vera are not in close apposition, which explains 



DEVELOPMENT OF THE OVUM. 35 

the occasional occurrence of menstruation up to that 
period. Sometimes this space is filled up with a fluid 
called " hydroperione." 

After the entrance of the ovum its attachment is 
almost immediately effected, the usual site being the pos- 
terior wall of the uterus near the entrance of the Fallo- 
pian tube through which it has just passed. Meanwhile, 
a succession of changes is going on within the ovum 
as follows : — 




Fig. 13. — Diagram of the area germinativa. In the centre is the primitive 
trace ; immediately surrounding it is the area pellucida, bounded by the dark area 
vasculosa. 

(a) Division of the blastoderm. At first, into two 
layers, an external or epiblast, and an internal or hypo- 
blast; subsequently, between these a third layer is de- 
veloped — the mesoblast, which at a later period under- 
goes subdivision. From these three layers all the tissues 
of the foetus are formed. 

From the epiblast are developed the epidermis with 
its appendages, the brain and spinal cord, and the organs 
of special sense. 



36 



OBSTETRIC SYNOPSIS. 



From the mesoblast are developed the corium, the 
muscles, bones, connective tissue, blood, bloodvessels, 
lymphatics, and genito-urinary organs. The mesoblast 
splits and each of the divisions turns inward, the outer 
one or somatopleure forming the abdominal walls, the 
inner or splanchnopleure the walls of the intestines. 

From the hypoblast are developed the epithelium of 
the intestinal canal and its numerous glands, also the 
epithelium of the respiratory tract. 




Fig. 14. — Transverse section of ovum in early stage of development (diagram- 
matic). — A, Epiblast ; B, mesoblast; C, hypoblast ; D, central portion (fluid); E, 
area germinativa ; F, lamina dorsales ; G, primitive trace and medullary groove. 

(b) Appearance of the area germinativa, which is a 
thickening of the cells of the epiblast ; it is oval in 
shape and has in its centre a collection of more translu- 
cent cells, the area pellucida. (Fig. 13.) 

(c) Appearance of the primitive trace. A groove in 
the middle of the area pellucida. The ridges at each 
side, called lamina dorsales, grow upward until they 
unite posteriorly and form a cavity within which the 
cerebro-spinal axis is subsequently developed. At the 



DEVELOPMENT OF THE OVUM. 



37 



same time processes grow forward and inclose the abdo- 
minal cavnVy. At the sides, in front and behind, folds 
or thickenings can be detected ; the most prominent of 
these marks the cephalic extremity of the embryo. 

(d) Formation of the umbilical vesicle or yelk sac. A 
temporary structure made up of most of the contents of 
the ovum ; its purpose is the nourishment of the embryo 
until other sources have been provided. 

By an infolding of the layers of the blastoderm to 
form the body of the embiyo the original vesicle is con- 




Fig. 15, — A section showing the origin and first traces of the amnion. — O, The 
umbilical vesicle; I, the mesoblast ; E, the epiblast; V, the zona pellucida; CC, 
origin of the cephalic and caudal amniotic hoods. 

stricted , and part of it is retained within the abdomen 
while the larger portion constitutes the umbilical vesicle. 
Its pedicle, the vitelline duct, contains the omphalo- 
mesenteric vessels and passes through an opening which 
corresponds with the umbilicus. 

(e) Formation of the allantois. A growth from the 
abdominal cavity of the embryo ; it commences after 
the twentieth day when the umbilical vesicle is shrink- 
ing, and is itself a temporary structure to provide a new 
source of nourishment. 
4 



38 



OBSTETRIC SYNOPSIS. 



Being constricted by the abdominal walls a smaller 
portion of the allantois remains inside and becomes the 
urinary bladder, its shriveled pedicle forming the urackus, 
while the larger or outer portion, which contains two 
arteries and two veins, grows rapidly in the direction 
of the walls of the ovum over the entire inner surface 
of which it spreads. One of the veins subsequently dis- 
appears. 

(/) Formation of the amnion. The inner of the two 
foetal membranes ; it consists of two portions, an inner 




Fig. 16. — The amniotic hoods more developed. — O, The umbilical vesicle; I, 
the mesoblast ; E, epiblast; E', a portion of the epiblast converted into amnion; 
E", the embryo ; C, limit of amniotic hoods ; V, zona pellucida. 

or true amnion, which incloses the foetus and the liquor 
amnii and covers the umbilical cord together with the 
foetal surface of the placenta, and an outer or false 
amnion which is spread out on the inner surface of the 
ovular walls. 

The amnion is derived from the epiblast and from 
the outer division of the mesoblast near the cephalic 
and caudal extremities ; at these points the two folds 
spring up and grow in the shape of a hollow wall until 



DEVELOPMENT OF THE OVUM. 



39 



they have surrounded the embryo and inclosed it within 
a shut sac — the amniotic cavity, which also contains 
the liquor amnii. 

The liquor amnii is an alkaline serous fluid clear at 
first, but becoming opaque or greenish toward the end 
of pregnancy ; contained as it is within the amniotic 
cavity it submerges the foetus, preserves it from shock 
or injury, facilitates the foetal movements which assist 
the development, protects the mother from the inconve- 




Yig 17 The amnion almost completed, also the origin of the allantois. — O, 

The umbilical vesicle; I, the intestines; E, the amnion; C, epiblast or non- vas- 
cular chorion; V, zona pellucida; C, amniotic hoods ready to close up; A, the 
allantois. 

nience of the movements, causes the uniform enlarge- 
ment of the uterus, prevents adhesions between the 
mother and the foetus, contributes to the nourishment 
of the foetus, and acts as a fluid wedge for dilatation of the 
os in labor. 

(g) Formation of the chorion. The outer of the two 
foetal membranes. As has been mentioned, the zona 
pellucida and its coating of albumen form the primitive 



40 



OBSTETRIC SYNOPSIS. 



chorion ; as soon, however, as the epiblast comes in con- 
tact with the inner surface of the zona pellucida the 
latter is partially absorbed by pressure, and by the union 
of its remains with the epiblast the true chorion is 
formed. Villi soon project from its surface, and when 
the allantois has reached the chorion each villus is sup- 
plied with a capillary loop which pushes its way to the 
apex and causes a rapid increase in growth. The villi 




Fig. 18. — The rapid development of the allantois and the disappearing of the 
umbilical vesicle (the zona pellucida almost atrophied). — O, Umbilical vesicle; E', 
amnion; E", epiblast; C, amniotic hoods coining in contact; V, zona pellucida 
almost entirely atrophied; A, allantois. 

themselves now give off branches which are supplied in 
the same manner, subsequently there are branches from 
these, and so on. (Fig. 20.) 

For a short time the villi grow equally over the 
entire surface of the ovum; but by the end of the 
second month those which are attached to the decidua 
serotina grow more rapidly, while those attached to the 
decidua reflexa begin to atrophy and very shortly have 
almost disappeared. 



DEVELOPMENT OF THE OVUM. 41 

Between the chorion and the amnion is a small space 
which is sometimes filled with a gelatinous fluid called 
" vitriform body ;" this fluid is probably the remains of 
the allantois, as it is not observed before the appearance 
of that vesicle. Sometimes the fluid exists in consider- 
able quantity, and should the chorion be ruptured at or 
near the end of pregnane} 7 it may escape and be mis- 
taken for the amniotic fluid. 



Fig. 19 — The allantois which has spread over the whole internal surface of the 
ovum sends capillary loops to the villi of the chorion ; the amnion incloses the 
umbilical cord more and more. — O, Umbilical vehicle; E', amnion; C, amniotic 
hoods in contact and forming but a single membrane; E", epiblast ; A, allantois; 
V, zona pellucida. 

(h) Formation of the ptecenta. The organ of nutri- 
tion and respiration for the foetus; it is a round or 
slightly oval mass from six to eight inches in diameter, 
weighs about twenty ounces, and is generally inserted on 
the posterior wall of the uterus near the fundus and one 
of the tubes. 

It begins to be distinct during the third month, but 

its formation is not complete until the end of that 

4* 



42 OBSTETRIC SYNOPSIS. 

month ; it increases in weight until the seventh month 
and then undergoes retrograde change. The internal or- 
foetal surface is smooth and covered hy amnion and 
has attached at or near its centre the umbilical cord, 
(Fig. 21.) 

The external or maternal surface is rough, friable, 
and furrowed by numerous sulci ; it is covered by a 
delicate membrane which unites the sulci and dips down 
between them. The openings of the arteries and veins 
can be seen upon this surface. (Fig. 22.) 




Fig. 20. — Chorionic villus magnified. — a, Epithelial covering ; b, band uniting 
it to another villus ; c, main arterial trunk of villus ; d, terminal vascular loops ; e, 
plexus of vessels between artery and vein. (x 350. ) 

The placenta consists of two portions, an internal or 
foetal, made up of the hypertrophied chorionic villi, and 
an external or maternal, made up of the deciclua serotina ; 
these two portions are so intimately blended that they 
form one organ. 



DEVELOPMENT OF THE OVUM. 43 

The villi of the chorion with their capillary loops 
are suspended in the greatly enlarged sinuses of the 




Fig. 21. — The placenta (internal or foetal surface). 

decidua which are filled with blood; so that the blood 
of the mother does not directly mix with that of the 
foetus. 




Fig. 22. — The placenta (external or uterine surface). 

0") Formation of the umbilical cord. The channel of 
communication between the foetus and placenta. Its 



44 OBSTETRIC SYNOPSIS. 

formation commences at the end of the fourth week ; at 
the middle of pregnancy it measures five to eight inches 
in length and at full term about twenty inches. 

It consists of two arteries and one vein, a gelatinous 
substance called Wharton's jelly, the remains of the 
allantois, the pedicle of the umbilical vesicle with its 
vessels, and an external layer from the amnion ; it is said 
to contain a few lymphatics and rudimentary nerves. 

The vessels which at first are straight become twisted, 
the arteries forming spirals around the vein ; the arteries 
enlarge in calibre as they approach the placenta, the only 
instance of the kind. 

The cord is usually attached near the centre of the 
placenta, but in some instances to the margin, consti- 
tuting the " battledore" placenta. True knots are some- 
times found in the cord. 



CHAPTER IY. 
FOETUS. 

The product of conception is called an embryo until 
the third month, or before the formation of the placenta; 
after that period the term foetus is used. 

I. DEVELOPMENT. 

(a) First month. At the end of the second week the 
embryo is a gelatinous mass about one line in length; at 
the end of the third week it has doubled in length, is 
nourished by the umbilical vesicle, the amnion is formed, 
and the allantois is carrying vessels to the chorion. At 
the end of the month the length is one-third of an inch, 
weight about forty grains ; the eyes, ears, and rudimen- 
tary extremities are distinguishable. 



FOETUS. 45 

(b) Second month. Length, one-half to one inch; 
weight, about one drachm. The umbilical vesicle is 
becoming smaller, while the villi of the chorion in con- 
tact with the deciclna serotina increase in number and 
size. 

The head, extremities, eyes, and ears are distinctly 
visible ; the Wolffian bodies begin to atrophy and are 
replaced by the kidneys ; points of ossification appear 
in the inferior maxilla and clavicle, and the umbilical 
cord is distinct. 

(c) Third month. Length, two and a half to three 
inches ; weight, seventy grains to one ounce. The um- 
bilical vesicle has disappeared, the chorion has lost most 
of its villi, and the placenta is formed. 

The decidua vera and decidua reflexa come in contact, 
thus filling the uterine cavity . The fingers and toes are 
distinguishable, also the sexual organs, but sex cannot 
be determined. 

(d) Fourth month. At the end of the fourth month 
the length is about six inches ; weight, four ounces. The 
bones of the skull are partly ossified, hair begins to grow 
upon the scalp, sex can be determined, and movements 
of the limbs commence. 

A foetus born at four months may live some hours. 

(e) Fifth r.ionth a Length, about ten inches; weight, 
about ten ounces. A down called lanugo covers the 
entire body, and the vernix caseosa, a greasy unctuous 
substance composed of epithelium and sebaceous secre- 
tion, begins to form upon the surface. The foetal move- 
ments are perceptible to the mother. 

(/) Sixth month. Length, about twelve inches; 
weight, a little more than one pound. Fat is deposited 
under the skin and the eyelids are closed. 



46 OBSTETRIC SYNOPSIS. 

A foetus born at six months breathes feebly, but 
generally dies in a few hours. 

(g) Seventh month. Length, thirteen to fifteen 
inches ; weight, three to four pounds. The eyelids are 
open and the testicles are near the scrotum. 

At the end of the seventh month the foetus is said to 
be " viable," but the majority of children born at this 
period die. 

(h) Eighth month. Length, sixteen to eighteen 
inches ; weight, four to five pounds. The membrana 
pupillaris has disappeared, the lanugo begins to disap- 
pear, and the insertion of the umbilical cord is near the 
middle of the body. 

(i) Ninth month (full term). Average length, twenty 
inches ; average weight, six and a half to eight pounds. 
Male children at birth exceed females both in size and 
in weight. 

2. FOETAL HEAD.— At the time of birth the bones 
of the cranium are not completely ossified nor firmly 
united, cartilage being interposed and permitting altera- 
tion of shape and position during labor. 

The membranous septa between the bones are called 
sutures, while the points at which the sutures meet are 
called fontanelles. 

There are four principal sutures : — 

(a) Sagittal, which separates the two parietal bones. 

(b) Frontal. A continuation forward of the sagittal 
suture dividing the frontal bone into halves. 

(c) Coronal. Separating the frontal from the parie- 
tal bones. 

(d) Lambdoidal. Separating the occipital from the 
parietal bones. 



FCETUS. 



47 



There are two fontanelles : — 

(a) Anterior, called bregma {moisture). Formed by 
the junction of the sagittal, frontal, and coronal su- 
tures; it is quadrangular in shape, and the larger of 
the two. 

(b) Posterior. Formed by the junction of the sagit- 
tal and lambdoidal sutures; it is triangular in shape. 

The fontanelles are distinguishable to the touch by 
tracing four lines from the anterior and three from the 
posterior. 

I 




Fig. 23. — The foetal skull (diameters).—^/*, Occipitofrontal ; om, occipitomental ; 
sb, sub-occipito bregmatic. 



The diameters of the foetal head are as follows (Play- 
fair) :— 

Occipito-mental .... 5.25 to 5.50 inches. 



Occipito-frontal 


. 4.50 to 5 


Sub-occipito bregmatic 


. 3.25 


Ceryico-bregmatic . 


. 3.75 


Bi-parietal 


. 3.75 to 4 


Bi-temporal 


. 3.50 


Fronto-mental . 


. 3.25 



In the majority of the cases of normal labor it is 



48 OBSTETRIC SYNOPSIS. 

the sub-occipito bregmatic diameter of the foetal head 
that is engaged in the pelvis. The foetus undergoes 
many changes of position in the uterus, but at the ter- 
mination of pregnancy in 96 per cent, of all cases the 
head is the presenting part. 




Fig. 24. — The usual position of the foetus. 

3. FCETAL CIRCULATION.— The purified blood 
returned from the placenta through the umbilical vein 
enters the foetus at the umbilicus and passes to the 
under surface of the liver, where a portion of it is dis- 
tributed, the greater part passing directly through the 
ductus venosus into the ascending vena cava, where it 
mixes with the blood from the trunk and lower extremi- 
ties and finally enters the right auricle of the heart. 



FCETUS. 



49 



io rv 




tf V 



50 OBSTETRIC SYNOPSIS. 

Guided by the Eustachian valve the blood passes 
through the foramen ovale into the left auricle and 
thence to the left ventricle ; from the left ventricle it 
goes through the aorta, chiefly to the head and upper 
extremities. Returning through the descending vena 
cava it is carried through the right auricle, in front of 
the Eustachian valve, into the right ventricle; thence it 
passes into the pulmonary artery through which a small 
portion goes to the lungs, but the greater part is carried 
through the ductus arteriosus into the aorta (descend- 
ing) and distributed to the lower extremities and to the 
placenta. 

The liver receives the purest blood; the head and 
upper extremities receive a richer and purer blood 
supply than the lower extremities, which accounts for 
their greater development. 

At birth when respiration is established the blood 
supply to the lungs is increased, and the ductus arterio- 
sus being no longer used is obliterated in a few days. 

The blood coming from the lungs fills the left auricle 
and prevents that which enters the right auricle passing 
through the foramen ovale ; so that this opening in a 
few days is entirely closed. Closure of the umbilical 
arteries and vein and of the ductus venosus occurs 
shortly after the blood has ceased flowing through 
them. 



MATERNAL CHANGES. 51 

CHAPTER Y. 
MATERNAL CHANGES. 

I. IN THE PELVIS.— The joints are swollen, softened, 
and more movable. 

The general pelvic hyperemia occurring at each 
menstrual period continues after impregnation, and on 
account of increased nutrition causes a marked growth of 
the uterus and its appendages, the mucous membrane, 
muscular walls, peritoneal covering, arteries, veins, 
nerves, and lymphatics being included in this change. 

The growth of the mucous membrane and formation 
of the decidual have been described. 

The growth of the muscular wall is more marked 
before the fourth month, and until that period it pro- 
gresses about as rapidly in extra-uterine as in intra- 
uterine pregnacy ; in the later months when its contents 
are undergoing more rapid development the uterine walls 
no longer increase in thickness, but by distension are 
somewhat thinned. 

The increased weight of the organ itself causes a 
sinking in the pelvis during the first months of gesta- 
tion ; this condition is usually attended by pelvic pains 
or dragging sensations. 

During the first months the development of the 
uterus is greater in the lateral than in the longitudinal 
direction. 

About the middle of the third month or the com- 
mencement of the fourth the fundus rises above the 
brim of the pelvis ; after this period (sixteenth to eigh- 
teenth week) the mother detects the foetal movements, 
when " quickening " is said to have taken place. 



52 OBSTETRIC SYNOPSIS. 

At the commencement of the sixth month the fundus 
has reached the level of the umbilicus ; during the 
seventh it is two inches above, and at full term is close 
to the edges of the ribs. 

A week or more before delivery, on account of relax- 
ation of the soft parts, the mass sinks somewhat into 
the pelvis, causing the patient to feel more comfortable 
as far as respiration is concerned. 

The uterus is usually inclined to the right side ; this 
is due either to congenital tendency, gravity — sleeping 
on the right side, or to pressure of a distended rectum 
or sigmoid flexure. The growth of the uterus does not 
materially affect the cervix; there is. however, a marked 
softening and an apparent shortening ; real softening of 
the cervix does not occur until within a few days or 
even hours before labor commences. 

The cervical canal is filled with a plug of mucus. 

The vagina has a purple or violet hue due to the 
venous congestion, and on account of its greater blood 
supply the vaginal pulse may be felt. Its secretions and 
those of the vulva are increased. 

2. IN THE BREASTS,— Changes may occur shortly 
after conception, but it is usually the second month when 
the breasts begin to enlarge, become tender, and are the 
seat of darting pains and sensations. The areola becomes 
more pigmented, and the sebaceous follicles — tubercles 
of Montgomery — are more prominent upon its surface. 
During the later months a secondary areola, lighter in 
color, surrounds the primary. The superficial veins 
enlarge, and milk is usually present. 

3. IN THE SKIN. — Beside the changes in the areolae 
of the breasts there is a tendenc}^ to pigmentation of the 
abdomen, face, and forehead. 



MATERNAL CHANGES. 53 

4. IN THE DIGESTIVE SYSTEM.— The appetite is 
often capricious or depraved. Gastric disturbance — 
probably reflex — is common before the fourth month ; it 
is manifested by nausea, and perhaps vomiting, which is 
usually limited to the early part of the day, and known 
as "morning sickness." There may be diarrhoea, but 
constipation is the rule. Profuse salivation sometimes 
but rarely occurs. 

5. IN THE NERVOUS SYSTEM.— The nervous sen- 
sibility is increased ; hysterical disorders, disturbance 
of the special senses, neuralgic affections, morbid crav- 
ings, changes in disposition and character are very 
common. 

6. IN THE CIRCULATION.— The quantity of the 
blood is increased ; it contains more water, less albumen, 
fewer red corpuscles, a slight increase in the number of 
the white, and during the later months of pregnancy a 
greater amount of fibrin. A temporary hypertrophy of 
the heart, particularly of the left ventricle, is said to be 
a constant occurrence. 

7. IN THE RESPIRATORY ORGANS.— As preg- 
nane}' advances the quantity of carbonic acid given off 
by the lungs is increased. On account of compression 
of the thorax embarrassed respiration may result. 

8. IN THE CRANIUM. — In pregnant women a bony 
formation called " osteophyte " is frequently found on 
the internal table of the cranial bones between the bone 
and dura mater ; similar deposits have been found on 
the inner surfaces of the pelvic bones ; they have also 
been noticed within the skulls of tuberculous subjects. 

9. IN THE URINE.— There is a larger quantity 
secreted on account of the increased arterial tension. 

5* 



54 OBSTETRIC SYNOPSIS. 

In the latter months compression of the renal vessels 
causes congestion, and albuminuria may result; in a 
small proportion of cases sugar is present in the latter 
months. The urine of pregnant women which has been 
allowed to stand thirty-six hours or more has formed 
upon its surface a scum called " kyestine" which in a 
few days breaks up and falls to the bottom of the vessel. 
This deposit consists of fat, phosphatic crystals, and 
bacteria, but having been found in the urine of the 
non-pregnant is no longer considered diagnostic of 
pregnancy. 



PART III. 

PREGNANCY. 



CHAPTER I. 
DIAGNOSIS OF PREGNANCY. 

The signs of pregnancy have been classified as pre- 
sumptive, probable, and certain; the following classifica- 
tion includes all of them : Symptomatic signs ; physical 
signs. 

I. SYMPTOMATIC SIGNS.— The symptomatic signs 
of pregnancy are : Cessation of menstruation; morning 
sickness; nervous disorders; pelvic disorders; quick- 
ening. 

(a) Cessation of menstruation. A sign of pregnancy 
when the menses have previously been regular ; in ex- 
ceptional cases menstruation continues throughout preg- 
nancy ; it commonly is regular until the third month, or 
before the decidual meet and fill the uterine cavity. 
During lactation it is normally absent, and exposure to 
cold, mental emotions, and debility may cause a sup- 
pression. 

(b) Morning sickness. A sign of pregnancy which 
is rarely absent; it may commence immediately after 
conception and continue until delivery, but is most com- 
mon during the early months. 

(c) Nervous disorders. These signs have been 
enumerated ; without the presence of others they are 
unreliable. 

(55) 



56 OBSTETRIC SYNOPSIS. 

(d) Pelvic disorders. Irritability of the bladder, 
pelvic pains and dragging sensations caused b}^ the 
increased weight and consequent slight prolapse of the 
uterus. 

(e) Quickening. The sensation felt by the mother 
about the sixteenth or eighteenth week of pregnancy ; 
it is produced by the movements of the foetus, which 
before were not perceptible. 

2. PHYSICAL SIGNS.— The physical signs of preg- 
nancy are: Mammary changes; pigmentary changes; 
enlargement of the uterus and abdomen; cervical and 
vaginal changes; ballottement ; intermittent uterine con- 
tractions ; foetal movements ; foetal heart sounds; uterine 
souffle; umbilical souffle. 

(a) Mammary changes. These have been described; 
in primiparae they are more valuable than in multipara, 
but in no instance should they be regarded as infallible 
signs. 

(b) Pigmentary changes. The dark band extending 
along the linea alba from the ensiform cartilage to the 
pubes and the other changes, which have been mentioned, 
are of some value as signs of pregnancy. 

(c) Enlargement of the uterus and abdomen. Gradual 
and uniform enlargement suggests pregnancy, especially 
if associated with other signs. During the latter months 
pouting of the umbilicus is an additional characteristic 
condition. 

Excessive deposit of adipose tissue, ascites, chronic 
metritis, retained menstrual fluid or abdominal and pelvic 
tumors may cause the enlargement. 

(d) Cervical and vaginal changes. Softening and 
apparent shortening of the cervix, increased secretion, 



DIAGNOSIS OF PREGNANCY. 5T 

vaginal pulsation, and violet coloration of the cervix, 
vagina, and vulva. All of these changes except the first 
may be caused by any pressure from above. 

(e) Ballottement. The sensation of a rebound im- 
parted to the finger after it has caused a momentary dis- 
placement of the foetus in the liquor amnii ; the tip of 
the finger should be placed just in front of the cervix. 
Ballottement is most successfully practiced between the 
fourth and seventh months. External ballottement is 
practiced by pressing the uterine contents with the two 
hands laid upon the abdominal wall and causing the 
foetus to float between them. 

(/) Intermittent uterine contractions. The alternate 
contractions and relaxations obtained by placing the 
hands over the uterine tumor upon which moderately firm 
pressure is being made ; as a sign of pregnancy it is not 
altogether reliable. 

(g) Foetal movements. When these can be felt by 
the examining hand they are a reliable sign of pregnane}^. 

(h) Foetal heart sounds. The most reliable of all the 
signs of pregnancy ; they are usually heard in the fifth 
month, but may be detected earlier. In the latter months 
in head presentations the sounds are heard below the 
umbilicus, the usual site being midway between the 
umbilicus and the left anterior superior spinous process 
of the ileum ; in presentations of the pelvis they are 
heard above the umbilicus. The pulsations vary from 
120 to 160 a minute, and are said to be slower in male 
and more rapid in female foetuses. 

(i) Uterine souffle. A blowing murmur synchronous 
with the maternal pulse ; its origin is in the large arte- 
ries of the uterine wall. This sound may be heard as 
early as the fourth month. 



58 OBSTETRIC SYNOPSIS. 

(j) Umbilical souffle. A hissing sound synchronous 
with the foetal heart; it is supposed to originate in the 
umbilical cord, is rarely heard, and is of no practical 
value. A rustling sound is described as occurring when 
the foetus is dead. 

3. DIFFERENTIAL DIAGNOSIS.— The conditions 
and diseases for which pregnancy may be mistaken, and 
vice versa, are as follows : Adipose enlargement of the 
abdomen and deposit of fat in the omentum; ascites; 
retained menses ; congestive hypertrophy ; uterine tumor ; 
ovarian tumor ; spurious pregnancy. 

(a) Adipose enlargement of the abdomen and deposit 
of fat in the omentum when associated with irregular 
menstruation may obscure the diagnosis hy preventing 
the detection of the uterus. The presence of fat in other 
portions of the bod} 7 and absence of the other signs 
are the indications of a non-pregnant condition. 

(b) Ascites. The history, the uniform distension, the 
fluctuation, the change of shape and of the percussion 
note when the position is altered, and the absence of the 
signs of pregnane}^ make the diagnosis almost certain. 

(c) Haemetometra (retained menses). The history, 
the periodical enlargement and distress, the long dura- 
tion and absence of most of the signs of pregnancy dis- 
tinguish it from that condition. 

(d) Congestive hypertrophy. The histoiy, the pain, 
the tenderness on pressure, absence of further develop- 
ment and of most of the signs of pregnancy should make 
the diagnosis almost certain. 

(e) Uterine tumor (fibroid). Regular or excessive 
menstruation, the hard, irregular, and inelastic enlarge- 
ment, the history and the absence of most of the signs 
of pregnancy will aid in the diagnosis. 



DURATION OF PREGNANCY. 59 

(/) Ovarian tumor (cystic). The generally regular 
menstruation, the fluctuation, the unilateral enlargement 
usually of slower progress than pregnancy, the history, 
the emaciation and general ill health, and the absence of 
most of the signs of pregnancy make the diagnosis easy. 

(g) Spurious pregnancy, which usually occurs in 
hysterical subjects, may be accompanied by many of the 
signs of pregnancy. The absence of most of the physical 
signs and the administration of an anaesthetic should 
enable one to make a differential diagnosis. 



CHAPTER II. 
DURATION OF PREGNANCY. 

The exact duration of pregnancy is still an uncer- 
tainty; an error of twenty-five days, the length of time 
between the end of one menstruation and the commence- 
ment of the next, is always possible. 

Counting from the cessation of the last menstruation 
to delivery, the average number of days is 278. 

Numerous instances of protracted gestation are on 
record. 

Various methods of predicting the date of confinement 
have been employed, among them are the following : — 

NaegeWs Method. Count seven days from the first 
appearance of the last menstrual period, and then reckon 
backward three months. 

Duncan's Method. Find the clay on which the female 
ceased to menstruate, or the first day of being what she 
calls' 4 well." Take that day nine months forward as 
2T5, unless February is included, in which case it is 



60 OBSTETRIC SYNOPSIS. 

taken as 273 days. To this add three days in the former 
case, or five if February is in the count, to make up the 
278. This 278th day should then be fixed on as the 
middle of the week, or, to make the prediction the more 
accurate, of the fortnight in which the confinement is 
likely to occur, by which means allowance is made for 
the average of either excess or deficiency. 

As quickening usually occurs shortty after the six- 
teenth week, the probable duration from that period can 
be calculated. 

CHAPTER III. 
ABNORMAL PREGNANCY. 

I. MULTIPLE PREGNANCY.— Twin births occur 
once in 87 labors ; triplets once in 7679. Cases are on 
record where four and five children have been given birth 
at one time. 

Multiple pregnancies are due either to the simultane- 
ous rupture of two or more ovisacs, to two or more 
ovules being contained within one ovisac, or to one 
ovule containing a double germ. 

The children are nearly always smaller in size and 
less perfectty developed than in single births. 

Abortions and monstrosities are more frequent in 
plural than in single pregnancies, while the triple and 
quadruple rarely, if ever, go to full term. 

In the case of twins the membranes and placenta are 
usually separate ; in rare cases both foetuses are contained 
in a common amniotic sac. 

In the case of triplets the membranes and placenta 
may be separate, but commonly there is one complete 



ABNORMAL PREGNANCY. 61 

bag of membranes, and a second having a common 
chorion with a double amnion. 

The diagnosis of multiple pregnancy is difficult and 
generally uncertain before the birth of the first child. 

Super •fecundation is the impregnation of one or more 
ovules after one has been impregnated and before the 
decidua lining the uterus has been formed. 

Superfcetation is the impregnation of a second ovule 
when the uterus already contains one which is undergo- 
ing development. 

2. EXTRA-UTERINE PREGNANCY.— The varieties 
of extra-uterine pregnancy are tubal; abdominal] and 
ovarian. 

(a) Tubal pregnancy may be caused by anything 
which diminishes the calibre of the tube, and is probably 
clue in many cases to inflammatory thickening of the 
coats of the tube which interferes with the progress of 
the ovum on its way to the uterus. Fright and shock 
are given as causes ; also, the accidental loss of the 
tubal epithelium, which it is claimed generally remains 
intact during menstruation. Tubal pregnancy usually 
terminates in rupture of the tube before the twelfth 
week ; a few cases, it is claimed, have gone to full term. 

(b) Abdominal pregnancy may result from the falling 
of an impregnated ovule into the abdominal cavity where 
it becomes attached and develops, or from the rupture 
of a tubal pregnancy. 

(c) Ovarian pregnancy, a very rare occurrence, is 
caused either by the penetration of the ovisac by a sper- 
matozoid, or by the impregnation of an ovule which has 
failed to escape from the ovisac after the latter has 
ruptured. 



62 OBSTETRIC SYNOPSIS. 

CHAPTER IV. 
DISORDERS OF PREGNANCY. 

The disorders which are liable to accompany the 
pregnant condition are as follows : — 

Of the digestive system; of the blood and circulatory 
system; of the genito-urinary system; of the nervous 
system ; displacements of the uterus. 

I. OF THE DIGESTIVE SYSTEM.— The disorders 
of the digestive sy stem are : — 

Nausea and vomiting, diarrhoea, constipation, hemor- 
rhoids, salivation. 

(a) Nausea and vomiting, called " morning sickness/ 7 
are common in the early months before quickening ; 
when that period has arrived there is usually a cessation 
of the distress; but it may continue throughout preg- 
nancy or become so serious as to endanger the mothers 
life unless abortion occur or be induced. 

These disorders are probably reflex in origin, and are 
caused by diseased conditions of the cervix, displace- 
ments of the uterus, or probably in most cases, by 
stretching of the uterine tissues; on the latter account 
they are more marked in frequency and severity in first 
pregnancies. 

Treatment. — Regulation of diet; regulation of bowels; 
correction of the acid gastric secretion with alkalies ; light 
breakfast in bed ; correction of uterine displacements 
and diseases; general hygienic surroundings. These 
measures failing:, the following drugs are useful: Bromide 
of sodium, oxalate of cerium, tincture of mix vomica, 
hydrocyanic acid (dilute), morphia, calomel, bismuth, 
carbolic acid, creasote, ipecac, pepsin, etc. 



DISORDERS OF PREGNANCY. 63 

When every remedy has failed, and the patient's life 
is in danger, the induction of abortion is justifiable. 

(b) Diarrhoea, which occasionally occurs, is due to 
error of diet or is of nervous origin. 

Treatment. — Regulation of diet, astringents, etc., and 
remedies as indicated. 

(c) Constipation is a more common disorder, and 
results from interference with the intestinal movements 
by pressure of the gravid uterus, and atony of the intes- 
tines caused by pressure and an altered state of the blood. 

Treatment. — Regulation of diet, mild laxatives, ner- 
vines, general tonics. All irritating or drastic cathartics 
should be avoided. Toward the end of pregnancy ene- 
mata and other mechanical means are sometimes neces- 
sary to remove an impaction of the rectum. 

(d) Hemorrhoids are of two varieties: external or 
venous ; internal or arterial. 

Treatment. — Regulation of bowels ; for the external 
variety, — the knife; for the internal, — an immediate re- 
duction of the protrusion followed by hot and sedative 
applications. 

(e) Salivation, though of rare occurrence, is some- 
times profuse. It is probably due to a deficiency of 
alkaline matter in the blood and secretions. 

Treatment. — The administration of alkalies and the 
use of astringent mouth washes. 

2. OF THE BLOOD AND CIRCULATORY SYS- 
TEM. — The disorders of the blood and circulatory 
system are : Anaemia ; hydrsemia ; varices ; oedema. 

(a) Anaemia is normally present; sometimes it re- 
quires tonics, iron, and a liberal diet. 

(b) Hydremia, a general oedema caused by an in- 



64 OBSTETRIC SYNOPSIS. 

crease in the watery portion of the blood. The dropsy 
may occur in the lower extremities only, but sometimes 
extends to the vulva, face, and upper portions of the 
bod} T , and may result in death of the foetus, miscarriage, 
or premature labor. 

Treatment. — Tonics, laxatives, diuretics, rest, symp- 
tomatic treatment. 

(c) Varicose veins are of frequent occurrence, being 
the result of pressure and increased blood supply. They 
occur most frequently from the second to the fifth months, 
and are found in the lower extremities (ext. saphenous 
veins), and in the vulva. 

Treatment. — Regulation of bowels, rest, elevation, 
removal of pressure, compression by bandage or elastic 
stocking. 

(d) (Edema of the legs is a result of hydraemia, of 
pressure, or of varicose veins ; the oedema often extends 
to the vulva. 

Treatment. — Regulation of bowels, rest and eleva- 
tion, removal of pressure, compression, diuretics, and 
diaphoretics. 

3. OF THE GENITO-URINARY SYSTEM.— The 
disorders of the genito-urinary s} T stem are: Albuminu- 
ria; diabetes; irritability of the bladder; leucorrhcea ; 
pruritus vulvae. 

(a) Albuminuria. The presence of albumen in the 
urine of pregnant women is a common occurrence ; ac- 
cording to some authors it is found in twenty per cent, 
of all cases; others make the percentage much smaller. 
In the majority of cases it is a temporary disturbance, 
disappearing after delivery and causing no unfavorable 
results. It occurs most frequently in first and twin 
pregnancies, and comes on during the latter months. 



DISORDERS OF PREGNANCY. 65 

The causes are, previous presence of albumen, pres- 
sure of the gravid uterus upon the renal veins causing 
congestion and changes in the kidney substance, increased 
work of the kidneys, increased arterial tension, and reflex 
irritation arising from the uterus. 

Albuminuria may induce abortion or cause death of 
the foetus; when the urinary secretion is lessened in 
amount or when there is retention of its elements in the 
blood, eclampsia may result. 

Treatment. — If the quantity of albumen is small and 
not accompanied by marked symptoms, no active treat- 
ment will be required. The diet should be regulated 
and all pressure removed ; a temporary removal of pres- 
sure from the renal vessels can be accomplished by caus- 
ing the patient to assume occasionally the knee-chest 
position or such position as will allow the abdomen to be 
suspended over the side of a bed or sofa. If the albu- 
men increases and oedema follows, active treatment should 
be commenced at once. 

The following remedies are useful : occasional saline 
cathartics, diuretics such as acetate or bitartrate of 
potassium and digitalis, diaphoretics, tonics such as 
iron, counter-irritation. When there is threatened or 
partial suppression of urine, colchicum shouid be used. 

As a last resort, when the mother's life is in danger, 
abortion or premature labor may be induced. 

(b) Diabetes renders conception unlikely, but when 
such does occur death of the foetus is liable to follow. 
The results to the mother are frequently serious. Gly- 
cosuria sometimes comes on in the latter months of 
pregnancy. 

(c) Irritability of the bladder and incontinence of 

6* 



66 OBSTETRIC SYNOPSIS. 

urine are often produced by displacements of the uterus, 
especially anteversion and anteflexion. 

Treatment. — Replacement and support of the uterus. 

(d) Leucorrhoea is generally due to a congestion of 
the vaginal mucous membrane ; it is more annoying in 
the latter half of pregnancy, and although it generally 
does not entirely disappear until after delivery, the dis- 
tress which it occasions may be greatly relieved. 

Treatment. — Removal of pressure, cleanliness, vagi- 
nal douches (carbolic acid, boracic acid, chlorate of 
potassium, chloride of sodium, alum, borax, zinc), medi- 
cated tampons. 

(e) Pruritus vulvae is of frequent occurrence, and may 
be very annoying; it is a result of leucorrhoea, varicose 
veins, or oedema of the vulva. 

Treatment. — Removal of pressure, treatment of the 
leucorrhoea, sedative applications ; in obstinate cases 
nitrate of silver or corrosive sublimate locally applied. 
Bromide of potassium is useful to allay the nervous irri- 
tability. 

4. OF THE NERVOUS SYSTEM.— The disorders 
of the nervous 'system are: Sleeplessness; neuralgise ; 
paralyses; chorea; affections of the respiratory organs; 
affections of the circulatory organs. 

(a) Sleeplessness requires hygienic surroundings and 
use of the bromides. 

(b) Neuralgiae of the face, mammae, and uterus are 
common. 

Treatment. — Attention to the health and teeth ; 
quinia, morphia, iron, sedative applications. 

(c) Paralyses of pregnancy are generally either hys- 
terical or uremic in origin. 



DISORDERS OP PREGNANCY. 67 

((/) Chorea may make its first appearance during 
pregnancy, but most frequently is a recurrence ; it is 
sometimes fatal to both mother and foetus. 

Treatment. — As in the non-pregnant condition the 
use of arsenic, the bromides, and iron. The induction 
of premature labor may be necessary. 

(e) Affections of the respiratory organs, including 
spasmodic cough and dyspnoea, are common disorders 
and may be very troublesome. 

(f) Affections of the circulatory organs, including pal- 
pitation and syncope, generally depend on the anaemic 
condition of the blood, but may be due to pressure of 
the gravid uterus on the diaphragm. 

5. DISPLACEMENTS OF THE UTERUS. -The 
displacements of the uterus are : Prolapse or procidentia ; 
anteversion or anteflexion; retroversion or retroflexion. 

(a) Prolapse of slight degree usually exists during 
the first three months of gestation. When prolapse or 
procidentia have existed before conception abortion 
usually results. At the fourth month the uterus begins 
to ascend and soon rises above the brim of the pelvis. 

(6) Anteversion or anteflexion in the early months 
may cause irritability of the bladder. In the latter 
months they sometimes cause separation of the recti 
muscles and produce the pendulous abdomen. 

(c) Retroversion or retroflexion. Pregnancy rarely 
occurs in a retroverted uterus, so that this condition if 
present is generally an accident coming on after preg- 
nancy has commenced. Retroflexion does not interfere 
with conception, but abortion is liable to follow. 

These displacements are the results of previous 
uterine disease, falls, distended bladder or pressure from 



68 OBSTETRIC SYNOPSIS. 

above (corsets, etc.). If abortion does not occur, the 
displacement is in the majority of cases corrected by 
the uterus rising out of the pelvis after the third month. 
There are on record a few cases in which the retroflex- 
ion continued until full term, one of Oldham's* in which 
he delivered a dead child, another occurring more re- 
cently in the practice of Prof. William S. Stewart ,f of 
Philadelphia, in which a living child was delivered. 



CHAPTER V. 
DISEASES OF PREGNANCY. 

The diseases and accidents liable to complicate preg- 
nancy are as follows : Intercurrent diseases ; pathologi- 
cal conditions of the decidua, ovum, and foetus ; abortion, 
"miscarriage, and premature labor. 

I. INTERCURRENT DISEASES.— The pregnant 
woman is liable to all diseases acute or chronic; the 
influences of these upon the mother and foetus vary 
greatly. 

(a) Continued fevers (typhoid, typhus, relapsing), 
usually induce abortion. 

(b) Eruptive fevers (smallpox, scarlet fever, measles), 
may cause abortion; the first is a grave complication, 

* London Obstetrical Society's Transactions, vol. i. 

f " The importance of careful diagnosis of pregnancy, with the 
history of a case of retroflexion going to full term ." Read before 
the Obstetrical Section of the Ninth International Medical Congress, 
held in Washington, D.C., September, 1887. 

This case had previously been diagnosed by several physicians 
" uterine fibroid/' and a day fixed for an operation for its removal. 
The patient coming under the notice of Professor Stewart the retro- 
flexion was discovered when it was too late for replacement with safety 
to the foetus . 



DISEASES OF PREGNANCY. 69 

but the latter, unless severe, are of little consequence as 
far as tlie mother's life is concerned. 

(c) Pulmonary diseases. Acute pneumonia is usually 
fatal to mother and foetus. 

Phthisis is usually a preventive of pregnancy, but 
pregnancy does not, as is generally supposed, retard the 
progress of the disease ; on the other hand, it is said to 
faA'or its development when there is an hereditary ten- 
denc}'. 

(d) Cardiac disease, whether previously existent or 
coming on during pregnancy, is a grave complication, 
the distress and danger being more marked in the latter 
months. 

(e) Syphilis, although liable to induce abortion or 
premature labor, is without immediate danger as far as 
the mother's life is concerned. 

It is during the secondary stage of the disease that 
abortion is most likely to occur, the syphilitic woman 
who becomes pregnant being more liable to abort than 
one who is pregnant and contracts syphilis; if the inocu- 
lation has occurred after the fourth month the danger 
to the foetus is slight. 

(/) Jaundice. Simple jaundice is quite common 
during the latter months of pregnancy. 

The malignant variety may occur earlier in pregnancy, 
and depends upon structural disease of the liver which 
is accompanied by acute yellow atrophy ; it results in 
almost certain death. 

(g) Carcinoma uteri, in the early period of the dis- 
ease, does not prevent conception. The growth may 
become great enough to interfere with natural delivery, 
but this is not a common occurrence. 



70 OBSTETRIC SYNOPSIS. 

2. PATHOLOGY OF THE DECIDUA, OVUM, AND 
FCETUS :— 

(a) Endometritis. Inflammation of the uterine mu- 
cous membrane may be acute or chronic ; the former 
variety, which is caused b} r acute febrile diseases, is 
characterized by hemorrhage and usualty followed by 
abortion ; the chronic form is usually the result of an 
endometritis existing previous to pregnancy, and 
although it does not always induce abortion the liabil- 
ity is increased. 

The decidua is usually much thickened, its internal 
surface may be studded with polypoid growths, and there 
is generally a process of fatty degeneration going on. 

(b) Hydrorrhea gravidarum. An intermittent dis- 
charge of a watery fluid from the pregnant uterus ; the 
fluid, which collects between the chorion and the decidua, 
is probably the result of a catarrhal endometritis ; it 
occurs most commonly in multigravidse, commencing 
about the third month of pregnancy. 

(c) Hydatidiform degeneration of the chorion, or 
vesicular mole. A disease of the chorial villi, the result 
of death of the embryo and transference of the develop- 
mental energy to the villi of the chorion, or of maternal 
disorders, such as endometritis, syphilis, etc. The 
growth of the mole is rapid, and in a short space of 
time the enlargement may be very great ; at about the 
third month profuse watery and bloody discharges make 
their appearance, and portions of the cysts may come 
away. As soon as it is recognized the entire mass should 
be removed, otherwise, it may remain in the uterus for 
months or years. 

(d) Diseases of the placenta. Inflammation, atrophy, 
fatty degeneration, hemorrhage, oedema. 



DISEASES OF PREGNANCY. 71 

The possibility of the occurrence of inflammation of 
the placenta, although it has been denied by some, is 
now generally believed ; the usual result of such inflam- 
mation is atrophy of the placenta followed by death of 
the foetus. Fatty degeneration is a result of death of 
the foetus or of maternal disorders which interfere with 
its nutrition (syphilis, etc.). The degeneration may be 
partial or complete; if it is at all extensive abortion 
will follow. 

Hemorrhage is usually the result of inflammation ; it 
rarely occurs, but if the effusions are large the pressure 
which they cause may interfere with the nutrition of the 
foetus. 

(Edema may be due to maternal or foetal disorders ; 
among the former may be mentioned general oedema of 
albuminuria, ascites from hepatic obstruction, etc.; among 
the latter, excessive secretion of amniotic liquor, obstruc- 
tion of the foetal circulation. 

(e) Hydramnion or polyhydramnios. An excessive 
secretion of amniotic liquor (more than two quarts). 
Various causes for this have been assigned, such as in- 
flammation of the amnion, morbid conditions of the 
decidua, disturbance of the maternal or foetal circula- 
tion. It occurs once in about 150 pregnancies; usually 
it does not commence before the fifth or sixth month, 
but very soon causes marked distension of the abdo- 
men and an exaggeration of the ordinary discomforts. 
The prognosis for the foetus is unfavorable. 

(/) Diseases of the foetus. Of those transmitted 
from the parent syphilis is most common and at the same 
time most fatal. Foetal syphilis may be transmitted from 
the father alone, from the mother alone or from both 



72 OBSTETRIC SYNOPSIS. 

parents ; and the mother may become affected through 
the embryo. 

If the mother be inoculated at or near the time of 
conception the infection of the foetus is almost certain ; 
if, however, she contract the disease at an advanced 
period of pregnancy (after the sixth month) the foetus 
may escape. 

When either or both parents are syphilitic, abortions 
are the rule, each product of conception being lost at a 
later period, until finally one may be alive at birth. A 
syphilitic child, if born alive, is small, poorly developed, 
has a hoarse cry and the well-known snuffles, and is 
covered with a characteristic eruption (usually pem- 
phigus), which is more marked upon the hands and feet. 

Intra-uterine amputations are due to constrictions by 
amniotic bands or by coils of the umbilical cord. 

(g) Death of the foetus. After its death the foetus is 
usually expelled from the uterus in two to fifteen da} T s; 
if it is a twin pregnancy and one foetus dies, both are 
commonly retained until the living one has matured ; 
even in single pregnancies the dead foetus may be re- 
tained a considerable time and undergo various changes. 

In the early months it may liquefy and leave no trace 
of its existence ; or degeneration of the chorial villi may 
occur and result in a " mole pregnancy " {vesicular mole) 
which may be retained within the uterus for some weeks, 
giving rise to attacks of pain and hemorrhage until it is 
expelled ; when there has been an extensive extravasa- 
tion of blood beneath the decidua so that the latter is 
torn through and clots have formed between it and the 
chorion or even in the cavity of the amnion, the ovum 
may be retained for a considerable time, during which 



DISEASES OF PREGNANCY. T3 

the coagulated fibrin, membranes, and placenta undergo 
secondary changes which lead to the formation of another 
variety of" mole pregnancy" (fleshy mole)] these fleshy 
moles are often retained for many weeks after death of 
the embryo or foetus, and give rise to the attacks of pain 
and hemorrhage which have been mentioned above. 

Mummification may occur in a foetus of three or four 
months if the membranes have not been ruptured. 

(li) Missed labor. A term applied to those cases in 
which a dead foetus is retained in the uterus beyond the 
period when pregnancy ordinarily terminates. 

3. ABORTION, MISCARRIAGE, AND PREMA- 
TURE LABOR. — By abortion is meant the expulsion of 
the ovum during the first three months of pregnancy, or 
before the formation of the placenta; by miscarriage, the 
expulsion of the foetus between the fourth and seventh 
months, or before the period of viability; by premature 
labor, the expulsion of the foetus between the seventh 
and ninth months, or between the periods of viability 
and full term of gestation. 

The terms abortion and miscarriage are used, as a 
rule, without regard to the distinction just made. 

Abortions are most common in multipara (twenty- 
three to three). About ninety per cent, of married 
women who live to the menopause have aborted. The 
relative frequency of abortions and deliveries at full 
term is, according to some, one to eight or ten; accord- 
ing to others, one to five. 

Women who have aborted once are more liable to a 

recurrence, either on account of the existence of the 

original cause or from an irritable or diseased condition 

of the uterus thus acquired. Abortions most frequently 

7 



74 OBSTETRIC SYNOPSIS. 

occur during the first three months at times correspond- 
ing with the menstrual flow, and particularly toward the 
end of the third month when the placental circulation is 
being established. Before this period the ovum generally 
comes away entire, and on this account may cause but 
slight disturbance. Later the placental adhesions are 
firm and are sometimes separated with difficulty, causing 
risks of hemorrhage and septicaemia. 

(a) Causes. These may be classified as paternal, 
maternal, and ovular. 

Paternal causes, although disregarded by some autho- 
rities, are generally admitted to exist. Of these syphilis 
is the most common, but the extremes of youth and old 
age and debilitated conditions are said to exert the same 
influence. 

Maternal causes are numerous, among them the fol- 
lowing are quite common : External violence ; falls ; heavy 
lifting; compression by clothing or corsets; compression 
of a varicose limb ; introduction of the uterine sound 
within the uterus ; applications to the cervix ; surgical 
operations, especially of the genital tract; coition; hot 
climate; hot baths; acute febrile diseases; syphilis; 
anxiety; fright; shock; constant suckling of a child at 
the breast; excessive vomiting or diarrhoea; obstinate 
constipation; the use of certain drugs (cathartics, laxa- 
tives, emetics, and emmenagogues) ; and morbid condi- 
tions of the uterus, such as inflammation of the uterine 
and cervical mucous membranes, irritability of the 
uterus, displacements (especially retroflexion), fibroids, 
and peritoneal adhesions. 

Ovular causes are diseases or imperfect development 
of the decidua, vesicular mole, placental hemorrhage 



DISEASES OF PREGNANCY. T5 

and degenerations, excess of amniotic liquor, diseases 
transmitted from the parents, torsion or compression of 
the umbilical cord, death of the foetus, the latter being 
the most frequent of all causes and the result of one or 
more of the disturbances mentioned. 

(b) Symptoms. Hemorrhage, slight or profuse, which 
ma} T accompany uterine contractions and pains or be fol- 
lowed by them. When both hemorrhage and pains are 
present from the first there can be but little hope of pre- 
venting the abortion. Before the third month, as has 
been mentioned, the ovum generally comes away entire, 
without rupture of the membranes ; after the third month, 
in the majority of cases, the membranes are ruptured so 
that the foetus is expelled first, the placenta and mem- 
branes following in a short time unless there should be 
a retention of them. 

(c) Prognosis. The immediate dangers of abortion 
are hemorrhage and septicaemia ; subinvolution, cellulitis, 
and endometritis are frequent results. 

The death-rate of criminal abortions is high; of those 
resulting from unavoidable causes it is said to be but 
little less than that of labor at full term. 

(d) Treatment. Prophylactic; of threatened abor- 
tion; of inevitable abortion. 

Prophylactic. Removal of cause (endometritis, re- 
troflexion, syphilis, etc.); rest in bed, especially at times 
corresponding with the menstrual periods; removal of 
all compression; avoidance of sexual intercourse. 

Threatened abortion. If the hemorrhage be not 
severe, if the amniotic liquor has not escaped, if there 
be but slight dilatation of the os, and little or no pain, 
the abortion may be prevented. Rest in bed, light and 



76 OBSTETRIC SYNOPSIS. 

unstimulating diet, avoidance of hot drinks, restoration 
of the uterus when displaced, anodynes (morphia, etc.), 
are indicated. 

Inevitable abortion. When the os is dilated and the 
ovum can be felt presenting at it, when the amniotic 
liquor has escaped, or when the hemorrhage is excessive 
and accompanied by r severe pains, abortion may be re- 
garded as inevitable. Where such is the case arrest of 
the hemorrhage and evacuation of the uterus are the 
two steps indicated. 

The means emploj-ed to effect these are tampons in 
the vagina and cervix, unless the ovum itself acts as a 
plug (tampons should not be introduced when there is a 
hope of preventing abortion, when used they must be 
changed every eight or twelve hours). Ergot, when the 
os is well dilated ; the finger for removal of the present- 
ing part; forceps; curettes, etc., for the removal of re- 
tained membranes, placenta, or portions of foetus. 

Rest in bed for several days should be insisted on, 
and during the entire period attention to cleanliness is 
most essential, symptomatic treatment being meanwhile 
employed. 



PART IV. 

LABOR. 



CHAPTER I. 
PHENOMENA OF LABOR. 

Labor usually occurs at a lime corresponding with 
the tenth menstrual period after conception. 

I. CAUSES. — The following causes of labor, none 
of which are entirely satisfactory, have "been assigned. 

(a) The efforts of the fcetus and supposed changes 
in its vascular system or its various organs were for a 
long time considered by the old obstetricians the causes 
of the onset of labor. 

(b) Distension of the uterus to a certain degree is said 
to be followed by a reaction in the form of uterine con- 
tractions ; in multiple pregnancies and excess of amniotic 
liquor the distension is often greater than at full term 
of normal pregnancy ; but, even in these cases, although 
the liability" is greater, abortions or premature labors do 
not always occur. 

(c) Fatty degeneration of the decidua is said to occur 
at the end of pregnancy and cause detachment of the 
ovum; in order to expel the foreign body which the 
uterus would thus contain, uterine contractions com- 
mence. 

(d) Irritability of the uterus, which is always more 
marked at the menstrual periods, especially during the 
early months of pre^nancv. increases during the latter 

> (77) 



78 OBSTETRIC SYNOPSIS. 

months until the time of the tenth menstruation after 
conception, when it is supposed to give rise to uterine 
contractions. 

(e) Changes in the placental circulation, by which the 
amount of venous blood in its sinuses is increased, are 
thought to exert an influence in this direction. 

It is doubtful whether any one of the above is an 
invariable cause of the commencement of normal labor ; 
several of them acting together may influence its onset ; 
but the active or immediate cause is the uterus itself and 
the contractions which it undergoes. 

2. MUSCULAR MECHANISM.— The expulsion of 
the child is effected, as has been mentioned, by the con- 
tractions of the uterus aided by the contractions of the 
abdominal muscles ; the former are not under the mother's 
control, the latter are only partly so. 

(a) Uterine contractions of the painless variety occur 
throughout pregnancy ; when labor commences thej T are 
accompanied by pain. 

These contractions are intermittent, the relaxations 
between them allowing the circulation which was tem- 
porarily checked to be re-established. The duration of 
one contraction varies, the average time being less than 
one minute; at the commencement of labor the}^ are of 
short duration and separated from each other by a con- 
siderable interval (one-half hour) ; but as the period of 
delivery approaches they become more frequent and in- 
tense (one to five minutes apart) and cause dilatation of 
the os. 

It was supposed by some that the contractions began 
in the cervix and passed gradually upward to the fundus, 
returning to the cervix; now it is believed that their ori- 



PHENOMENA OF LABOR. 79 

gin is at the fundus, and that they pass downward in a 
wave-like motion to the cervix. 

During contraction the uterus becomes more globu- 
lar, its transverse diameter is diminished, and its antero- 
posterior increased ; the cervix becomes dilated and 
thinned, while the body and fundus are thickened. The 
broad and round ligaments also contract, the latter, by 
their contractions, drawing the fundus forward against 
the abdominal wall. 

(b) Abdominal contractions add force to the uterine 
action in effecting expulsion; at first the efforts are 
voluntary, but finally, like the uterine contractions, 
they cannot be controlled by the patient. 

(c) Labor-pains vary greatly in their intensity in 
different women; during the first stage of labor the 
pains come on with the uterine contractions and disap- 
pear with them; they are felt over the sacrum from 
which they radiate to the abdomen and thighs ; they 
are described as dull-aching or grinding, being caused 
by compression of the nerve filaments during the con- 
tractions and to dilatation and stretching of the cervix. 
When the os is fully dilated the character of the pains 
changes ; the expulsion or bearing-down pains then 
commence, and the suffering becomes more intense both 
on account of the pressure of the head upon the sacral 
plexus, which causes the pains and cramps in the thighs, 
and on account of the stretching of the soft parts. 

3. STAGES OF LABOR.— The stages of labor are : 
Premonitory, first, second, third. 

(a) Premonitory symptoms usually commence a week 
or two before delivery ; sometimes, however, labor sets 
in suddenly without their occurrence. 



80 OBSTETRIC SYNOPSIS. 

On account of relaxation of the soft parts the uterus 
sinks deeper into the pelvis, while the fundus falls more 
forward, thus lessening the pressure above and relieving 
somewhat the respiratory and gastric disturbances. 

Another result of the " sinking " of the uterine mass 
is increased pressure upon the lower pelvic contents and 
consequent irritability of the bladder and bowels, diffi- 
cult walking, hemorrhoids, and increased oedema of the 
lower extremities. 

The uterine contractions may become manifest to 
the woman herself, and may be accompanied by occa- 
sional slight pains ; the pains, or painful contractions, 
may become so severe that labor is thought to have set 
in, but it will be found that these " false pains," as they 
are called, which are felt most in front, have no effect in 
dilating the os, and are kept up by some local irritation. 
An enema will often cause their disappearance. 

During this stage a real shortening of the cervix 
generally occurs and indicates commencing dilatation ; 
the mucous discharge from the cavity of the cervix 
becomes more abundant, and may be tinged with blood 
from the lacerated capillary bloodvessels ; the external 
genitals are swollen and moistened by their own and the 
vaginal secretions which are poured out in greater quan- 
tity. 

(6) First stage. The first stage, called that of dilata- 
tion, is from the commencement of effective pains till 
complete dilatation of the external os. 

The dilatation is effected in three ways— by mechani- 
cal stretching by the amniotic liquor contained within its 
sac (or in the absence of this by the presenting part of 
the foetus) ; by contraction of the longitudinal muscular 
fibres ; by relaxation of the circular fibres. 



PHENOMENA OF LABOR. 81 

During this stage the woman is generally able to be 
about ; as dilatation advances the pains recur at shorter 
intervals and become more severe ; the temperature is 
elevated, and during each pain there is an acceleration 
of the pulse ; the genitals are covered with a very 
copious secretion which lubricates and relaxes them, 
and also indicates a rapid termination of labor ; the 
membranes protrude farther during each pain and ma}' 
extend to the vulva, but should not rupture until the 
dilatation is complete. Sometimes they remain intact 
until the head has passed the vulva, when the child is said 
to be born with a u caul ;" in rare cases the ovum is expelled 
entire. If rupture do not occur when the dilatation is 
complete labor is generally delayed ; when rupture oc- 
curs all of the fluid does not immediately escape, but 
continues to ooze out at the commencement of each 
pain, and some is usually retained until after the birth 
of the child. At the termination of the first stage of 
labor the cervix and vagina form a continuous canal. 

(c) Second stage. The second stage, called that of 
expulsion, is from dilatation of the external os till com- 
plete extrusion of the child. If the membranes rupture 
when the dilatation is complete the character of the pains 
is entirely altered ; at first there is a short cessation; then, 
assisted by the abdominal contractions, more powerful and 
prolonged pains of a bearing-down nature come on, follow- 
ing each other in quick succession until the head is born. 
In order to aid in the expulsion the breath is held, the 
feet are involuntarily placed against some support, and 
the hands grasp anything that is within reach. After 
the exit of the head the body is generally expelled by 
the next pain; a gush of amniotic liquor mingled with 



82 OBSTETRIC SYNOPSIS. 

blood immediately follows and terminates the second 
stage of labor. 

(d) Third stage. The third stage, called that of the 
after-birth, is from expulsion of the child till complete 
extrusion of placenta and membranes. 

During the first part of this stage the pains cease for 
a short time, but with the uterine contractions they 
commence again, continuing with intermissions until 
the placenta and membranes have been expelled into the 
vagina or through the vulva ; if left to itself the placenta 
is usually expelled spontaneously with little hemorrhage, 
its lower margin coming first. If traction has been 
made on the cord it generally comes down with its foetal 
surface foremost, and by suction on the uterine vessels 
causes blood to be poured out from them. By detach- 
ment of the placenta the maternal vessels are torn across, 
but hemorrhage is prevented by the formation of clots 
and by the uterine contractions. 

At the termination of the third stage of labor the 
uterus should be firmly contracted so that it can be felt 
in the hypogastric region about the size of a foetal head. 

For several hours or da} T s, especially in multiparas, 
alternate contractions and relaxations are liable to occur 
and give rise to the so-called " after-pains." 

4. DURATION OF LABOR.— Labor is usually 
longer and more difficult in primiparas than in multi- 
paras ; also in primiparas beyond the age of thirty years 
than in those under that age, and with male than with 
female children. 

The usual duration of labor in primiparas is probably 
twelve to twenty hours ; in multiparas, six to ten hours. 
The first stage is longer than the second, the relation 



MECHANISM OF LABOR. 83 

which they bear to each other being variously estimated 
at from one to two, to one to four or five. 

The second and third stages of labor may be com- 
pleted at the same time by the immediate expulsion of 
the after-birth; the third stage usually terminates in 
about twenty minutes after the second, but may be greatly 
prolonged. 



CHAPTER II. 
MECHANISM OF LABOR. 

The presentations of the foetus at the pelvic brim may 
be classified as three, viz: Presentation of the head; 
presentation of the pelvis; presentation of the trunk 
(transverse presentation). The number of the positions 
of each presenting part is four, and corresponds with 
the number of quadrants into w r hich the pelvis is divided 
by antero-posterior and transverse lines, the name being 
the same as that of the quadrant in which it lies. 

I. PRESENTATIONS OF THE HEAD.— Head pre- 
sentations are diagnosed by abdominal palpation, by 
hearing the foetal heart-sounds below the umbilicus, and 
by the vaginal touch. 

There are three varieties of head presentation : of the 
vertex or occiput; of the face; of the brow. 

(a) Vertex presentations occur in about ninet} r -five 
per cent, of all cases of labor. The antero-posterior 
diameter of the head enters the pelvis at the brim in 
either a transverse, an oblique, or an intermediate di- 
ameter with the occiput anterior or posterior; in the 
cavity it occupies an oblique diameter. 

The positions of the vertex are four, being named 



84 OBSTETRIC SYNOPSIS. 

according to the pelvic quadrant in which the occiput 
lies. They are as follows : — 

First Position or Left Occipito- Anterior (l. o. a.). — 
The occiput at the left acetabulum. 




Fig. 26. — Vertex presentation. First or left occipito-anterior position. 

Second Position or Right Occipito- Anterior (it. o. a.). 
-The occiput at the right acetabulum. 




Fig. 27. — Vertex presentation. Second or right occipito-anterior position. 

Third Position or Bight Occipito-Posterior (it. o. P.) 



MECHANISM OF LABOR. 



85 



— The occiput at the right sacro-iliac joint. (The reverse 
of the first position.) 




Fig. 28. — Vertex presentation. Third or right occipito-posterior position. 

Fourth Position or Left Occipito-Poste7 % ior (l. o. p.). 
— The occiput at the left sacro-iliac joint. (The reverse 
of the second position.) 

4 




Fig. 29. — Vertex presentation. Fourth or left occipito-posterior position. 

The first position is the one usually met with ; the 
fourth is least common. 

8 



86 OBSTETRIC SYNOPSIS. 

The movements undergone by the head in its expul- 
sion are as follows : (I) flexion, (2) descent, (3) internal 
rotation, (4) extension, (5) external rotation, the latter 
movement being followed by (6) expulsion of the body. 

Flexion is a bending of the chin toward the chest to 
accommodate the foetal head to the canal of the pelvis 
by substituting a shorter diameter — the suboccipito- 
bregmatic, for a longer one — the occipitofrontal. 

Descent accompanies and follows flexion, the antero- 
posterior diameter of the head being in the oblique 
diameter of the pelvis. 

Internal rotation is a movement of the head and trunk 
from the oblique to the antero-posterior diameter; always 
in first and second positions, and usually in third and 
fourth positions the occiput turns in front under the 
pubic arch. 

Extension is the result of the head being pushed 
against the resisting perineum; the neck is fastened 
under the pubic arch, and while the pressure from above 
and below is continued the head is rolled out of the vul- 
var opening. 

External rotation is a turning of the head from the 
antero-posterior to the transverse position after its ex- 
pulsion and as soon as the uterine contractions are re- 
newed. The occiput rotates to the side at which it 
originally was. 

Expulsion of the body is usually effected by the next 
pain; the sub-pubic shoulder makes its appearance first, 
but, as a rule, the posterior one is first disengaged. 

(b) Face presentations occur once in about 250 labors. 
They are due to a backward extension of the head the 
reverse of flexion, the extension being the result of 



MECHANISM OF LABOR. 



87 



either lateral uterine obliquity, pelvic narrowing, en- 
largement of the neck and thorax or unusual size or 
shape of the head. 




Fig. 30. — Extension of the foetal head. 

Face presentations are diagnosed with certainty by 
the vaginal touch. 

The positions of the face are four, being named ac- 
cording to the pelvic quadrant in which the forehead 
lies. (They are sometimes named from the position of 
the chin.) 

First Position or Left Fr onto- Anterior (right mento- 
posterior). — The forehead at the left acetabulum. 

Second Position or Right Fr onto- Anterior (left mento- 
posterior). — The forehead at the right acetabulum. 

Third Position or Right Fronto-Posterior (left mento- 
anterior). — The forehead at the right sacro-iliac joint. 
(The reverse of the first position.) 



88 



OBSTETRIC SYNOPSIS. 



Fourth Position or Left Fronto-Posterior (right mento- 
anterior). — The forehead at the left saero-iliac joint. (The 
reverse of the second position.) 

As in positions of the vertex, the first position is the 
one usually met with ; the fourth is least common. 

The movements undergone closely correspond with 
those of the vertex ; they are as follows : (1) Extension, 




Fig. 31. — Presentation of the face at the pelvic brim in the second facial position. 

(2) descent, (3) internal rotation, (4) flexion, (5) ex-> 
ternal rotation, (6) expulsion of the body. 

Labor in face presentations will generally terminate 
naturally, but in the majority of cases the prognosis foi 
the child is unfavorable. 

(c) Brow presentation is an intermediate between 



MECHANISM OF LABOR. 89 

flexion and extension or presentation of the vertex and 
that of the face. 

It usually exists as such at the pelvic brim ; when 
the head enters the pelvis either flexion or extension 
must occur before delivery can be effected, as it is the 
largest diameter of the head that is engaged. (The 
occipito-mental diameter.) 

The head may be arrested in this position ; assist- 
ance will then be required. 

Brow presentations are diagnosed by the vaginal 
touch, the anterior fontanelle, orbit and root of the nose 
being easily distinguished. 

2. PRESENTATIONS OF THE PELVIS. — Pelvic 
presentations are diagnosed by abdominal palpation, by 
hearing the foetal heart-sounds on a level with or above 
the umbilicus and by the vaginal touch ; they occur once 
in about thirty to forty labors and are more common with 
premature births, hydrocephalic or dead foetuses, with 
excess of the amniotic liquor, contractions of the pelvis 
and laxity of the uterus and abdominal walls. The 
results to the mother are not unfavorable; but the infan- 
tile mortality is much higher than in presentations of 
the vertex. 

There are two varieties of pelvic presentation : Of 
the breech ; of the foot or knee. 

(a) Breech presentations. About 60 per cent, of 
pelvic presentations are of the breech. 

The positions of the breech are four, being named 
according to the pelvic quadrant in which the sacrum 
lies. 

First Position or Left Sacro- Anterior. — The sacrum 
at the left acetabulum. 



90 OBSTETRIC SYNOPSIS. 

Second Position or Bight Sacro- Anterior. — The sac- 
rum at the right acetabulum. 




Fig. 32. — Presentation of the breech in the first or left sacro-anterior position. 

Third Position or Bight Sacro-Posterior. — The 
sacrum at the right sacro-iliac joint. 

Fourth Position or Left Sacro-Posterior. — The sacrum 
at the left sacro-iliac joint. 

The first position is the most common of these. 

The movements undergone are as follows : (1) Com- 
pression of the pelvis, (2) descent , (3) internal rota- 
tion, (4) delivery of the body, (5) external rotation, 
(6) expulsion of the head. 

(b) Foot op knee presentations often occur with those 
of the breech, delivery being accomplished in the same 
way. 

In making examination by the touch the foot ma} 7 be 
mistaken for the hand; it should be remembered that the 
toes are shorter and all in the same line, that the great 



MECHANISM OF LABOR. 91 

toe cannot be brought in apposition with the others as 
the thumb can with the fingers, that the foot is larger 
and narrower, the outer border being thin and rounded 
while the inner is thick and hollowed. The knee may 
be mistaken for the elbow, but is distinguished by its 
larger size and by the patella. 

3. PRESENTATIONS OF THE TRUNK (transverse 
presentations). — Transverse presentations are diagnosed 
by abdominal palpation and by the vaginal touch ; they 
occur once in about 260 labors, and are more common 
with premature or dead children, with excess of amniotic 
liquor, pelvic deformities and laxity of the uterus with 
increase in its transverse diameter. 

The prognosis for both mother and child is more un- 



FiG. 33. — Presentation of the right shoulder with the arm hanging down. 

favorable than in face presentations ; natural delivery 
by spontaneous version or evolution is rarely accom- 
plished, and an early interference is therefore necessary. 
In nearly all cases of transverse presentation the 
shoulder occupies the pelvic brim ; the elbow or hand 



92 OBSTETRIC SYNOPSIS. 

ma} T come down and protrude from the vulva. When 
the hand presents the position of the foetus can be de- 
termined by finding out which hand it is ; if it be the 
right, and the palm turn upward, the thumb will point 
to the right side of the mother, and vice versa. 

The positions of the trunk are generally classified as 
two ; they depend on the relation of the back of the foetus 
to the abdomen of the mother, and are known as dor so- 
anterior and dor so-posterior ; the former is the most 
common of these. 

Taking into account the iliac fossa in which the head 
lies, these may be subdivided into four positions as fol- 
lows : — 

First Position or Left Dor so- Anterior. — The back at 
the left acetabulum. 

Second Position or Eight Dor so- Anterior. — The back 
at the right acetabulum. 

Third Position or Right Dorso-PosteiHor. — The back 
at the right sacro-iliac joint. 

Fourth Position or Left Dorso-Posterior. — The back 
at the left sacro-iliac joint. 

In spontaneous evolution the movements undergone 
are as follows: (1) Compression of the shoulder, (2) 
descent, (3) internal rotation, (4) delivery of the body- 
(5) external rotation, (6) expulsion of the head. 



CHAPTER III. 

MANAGEMENT OF NORMAL LABOR. 

When the accoucheur is summoned he should go at 
once ; by prompt attendance he may prevent various 
accidents to both mother and child, or have a better 



MANAGEMENT OF NORMAL LABOR. 93 

opportunity for correcting any malpresentation that may 
exist. 

The following articles may be required, and should 
if possible be taken along: Obstetric forceps; a pocket 
case of instruments ; a catheter ; needles (curved or 
straight) ; a needle holder ; silk or wire for sutures ; a 
hypodermic syringe ; a stethoscope ; Barnes' dilators ; 
ergot ; ether ; chloroform ; chloral ; morphia ; Monsel's 
solution of iron. The syringe (vaginal and rectal), scis- 
sors, thread, and abdominal bandage are usually fur- 
nished by the patient or nurse. 

The room should be airy and quiet, the bed of easy 
access and not too low; the bedding firm (not feather) 
and protected by a waterproof sheet (rubber or oil- 
cloth), or, in the absence of this, by several thicknesses 
of paper, either being covered with a blanket or cloths 
which will absorb the discharges. 

The patient should be in her ordinary night dress, 
underneath which a special petticoat is worn ; while out 
of bed the night dress is covered by an outside wrapper, 
but when delivery approaches the latter is removed, the 
night dress tucked up under the arms, and the petticoat 
left to cover the patient. The position of the patient 
when in bed varies in different countries, the usual ones 
being on the Lack or on the left side. 

On the back the progress of labor in the first stage 
is more rapid, as the weight of the child, assisted by 
more effective abdominal contractions, stimulates the 
uterus to greater action. 

On the left side the exposure is less, the right lateral 
obliquity is overcome, the pressure upon the perineum 
is less, and the risks of its rupture diminished. 



94 OBSTETRIC SYNOPSIS. 

Before the bead has reached the pelvic floor, the 
dorsal position between sitting and lying is altogether 
the most favorable ; during expulsion, a kneeling or 
squatting position is the most effective, but attended 
by greater risks to the perineum. 

I. EXAMINATION OF THE PATIENT.— The lying- 
in room should not be entered abruptly, nor, when there 
is nothing urgent, should an immediate examination be 
made. 

The presence of the accoucheur usually causes a 
temporary cessation of the pains ; during this time he 
may inquire when the pains commenced, of their fre- 
quency, character, and situation, of the presence of a 
"show," of the state of the bladder and bowels, of the 
character of former labors — if the patient is not a primi- 
para — and of her condition during the present preg- 
nancy. 

Having secured the confidence and consent of the 
patient, an examination may be made. The hands 
should first be washed in warm carbolized w^ater, for 
cleanliness and to increase the delicacy of touch. If 
possible, an examination of the abdomen by palpation 
and auscultation should be made, in order that the posi- 
tions of the uterus and foetus and the presence of foetal 
life may be ascertained. 

The vaginal examination is generally commenced 
during a pain, but should be continued during the in- 
terval of the pains ; it is conducted in the usual manner 
with the patient on her back or left side. 

The object is to discover the condition of the va- 
gina; the capacity of the pelvis; the state of the cervix 
and os (soft or dilated) ; the condition of the membranes 



MANAGEMENT OF NORMAL LABOR. 95 

(whether ruptured or unruptured) ; the presentation 
and the position. 

If the membranes are intact, great care is necessary 
to avoid their rupture ; before their rupture it is diffi- 
cult to ascertain the exact position of the vertex, "which 
is usually the presenting part in a normal case ; as soon 
as rupture has occurred the fontanelle (usually, the pos- 
terior) and sutures can be distinctly felt. 

In addition, the following information should be ob- 
tained by the examination: — 

Whether there is a condition of pregnancy; 

Whether labor has commenced; 

Whether it is the first or second stage of labor; 

Whether the presentation and position are normal; 

Whether the patient can be left for a while with 
safety. 

A guarded opinion should invariably be given as to 
the probable duration of the labor ; if the pains are in- 
frequent and weak, and the cervix is rigid and but 
slightly dilated, a considerable delay may be expected, 
and the attendant may leave for a short time. 

2. FIRST STAGE OF LABOR.— During this time 
the patient should be encouraged to remain out of bed, 
to sit, stand, or walk about, but not to exhaustion; if 
she lie it should be on her back. An occasional vaginal 
examination should be made to note the progress and 
general condition; these should not be too frequent, nor, 
as a rule, should any assistance in the dilatation of the 
os be attempted. The patient should be restrained 
during this stage from all bearing-down efforts ; the 
urine should be passed from time to time, and, on 
account of the patient's frequent desires in this direc- 



96 OBSTETRIC SYNOPSIS. 

tion, the attendant should occasionally absent himself 
from the room; if there is retention of urine it will be 
necessar} T to use the catheter; the bowels should be 
evacuated, and for this purpose an enema is usually 
given; an occasional vaginal injection of some antiseptic 
solution should be used. 

Toward the termination of the first stage the patient 
should undress and lie upon the bed. 

When the dilatation is complete the membranes 
usually rupture, part of the amniotic liquor pours out, 
the head descends, and on renewal of the pains the 
second stage of labor begins; if rupture does not occur 
at this time the labor may be considerably delayed, 
and to avoid this, artificial rupture should be resorted to 
during a pain by means of the finger nail or with some 
pointed instrument. 

3. SECOND STAGE OF LABOR.— During this time 
the patient usually remains in bed, but change of posi- 
tion and occasional sitting up if desired may be allowed. 
The customar}' position being on the left side with the 
knees drawn up, the nates parallel to the edge of the 
bed, and the body lying across it, the feet should rest 
against the foot-board while the hands may grasp a towel 
or sheet tied to the foot of the bed. 

As soon as the membranes are ruptured a vaginal 
examination should be made, the exact position of the 
head or presenting part ascertained, and any malposi- 
tion or prolapse of the cord or of the extremities cor- 
rected if possible. 

During this stage the examinations should be much 
more frequent than during the first, and the patient may 
be urged to " hold her breath" and "bear down" while 
the feet are supported and the hands pull on the towel. 



MANAGEMENT OF NORMAL LABOR. 97 

In the intervals between the pains the anterior lip of 
the os uteri, should it become engaged between the head 
and the pubic bone, may be pressed up and held during 
the next contraction or until the head has passed be- 
yond it. 

Too rapid descent or expulsion of the head should 
be avoided that there may be less risk of rupturing the 
perineum; when the perineum is distended the patient 
should cease all voluntary efforts, and attempts may be 
made to preserve it intact by pulling the perineum for- 
ward over the head by means of two ringers in the rec- 
tum, pressure being at the same time made by the thumb 
upon the head in order to restrain its progress. 

Another method, as effective and less repulsive, is to 
push the perineum forward over the head by the thumb 
and finger placed on either side of it, the pressure upon 
the head by the tips of the fingers being kept up as before. 

When rupture seems inevitable, episeotomy, the 
making of lateral incisions through the vulva, is recom- 
mended by some authorities; many others are opposed 
to the operation. 

As soon as expelled the head should be supported by 
the right hand and its rotation assisted; it should be 
ascertained whether the cord surrounds the neck, and, 
if so, it should be gently drawn over the head ; if this is 
not possible, and there is danger of choking the child, it 
may be quickly ligated in two places and divided be- 
tween them. With a recurrence of the contractions and 
pains the shoulders are usually delivered, and in many 
instances are the cause of rupture of the already weak- 
ened perineum. 

In delivery of the body little or no force should be 
9 



98 OBSTETRIC SYNOPSIS. 

employed, but moderate pressure maybe made upon the 
abdomen that the uterus may contract as its contents 
are expelled. 

Ergot by the mouth or hypodermically is sometimes 
given at this period in order to assist in the permanent 
contraction of the uterus, and to prevent post-partum 
hemorrhage. 

Unless there is immediate necessity for its use, the 
administration, if made at all, should be deferred till 
after removal of the placenta. The child's mouth having 
been cleaned of secretions, it should be allowed plenty 
of air, and, if necessary, respiration may be assisted or 
excited by friction upon the chest, a dash of cold water, 
or, in extreme cases, by artificial respiration. 

A strong and healthy child begins at once to breathe 
and usually cries; in such cases it is the practice of some 
to ligate the cord immediately, but it is better to defer 
this until the pulsations cease or become feeble (one to 
five minutes), as the child is receiving an additional sup- 
ply of blood during this time. 

The ligature commonly used consists of several 
strands of strong thread tied together at both ends ; it 
is applied about one and a half to two inches from the 
umbilicus, and after division of the cord with scissors 
one-half inch beyond this point, for greater safety, a 
second ligature may be applied near the cut end, the clots 
and gelatinous contents having been first pressed out. 

It is unnecessary, except for cleanliness, to ligate the 
placental end of the cord unless the bleeding be profuse 
or a twin foetus remain in the uterus. 

4. THIRD STAGE OF LABOR.— The proper man- 
agement of this stage of labor is most important ; the 



MANAGEMENT OP NORMAL LABOR. 99 

duties of the attendant are : to guard against hemor- 
rhage; to promote uterine contractions ; and to further 
the expulsion of the placenta. 

The patient should lie on her back, and till the pains 
return should be allowed to rest, the condition of the 
uterus being carefully noted by gentle abdominal pres- 
sure. 

Traction on the cord should be avoided unless the 
placenta be detached and in the vagina. In tbe majority 
of cases the uterine contractions recur in ten to fifteen 
minutes, when the placenta is expelled without assist- 
ance and with slight loss of blood. 

The method usually employed, whether there be re- 
tention of the placenta or not, is known as Crede's ; it 
is practiced as follows : — 

When the contractions begin to recur stimulate them 
by gentle pressure and friction over the fundus and body 
of the uterus; when active contractions commence grasp 
the hard fundus with the hand and compress it between 
the thumb and fingers, at the same time making down- 
ward pressure upon the organ. 

By the use of this method during a single pain, or 
during several successive ones, the placenta is detached 
and expelled into the vagina; if the pressure be con- 
tinued it may be forced out of the vulva. Occasionally, 
when the placenta is detached it will remain in the 
vagina for some time ; if the lower margin can be felt it 
may be seized with the thumb and finger and gently 
drawn out of the vulva, being turned around several 
times that the membranes trailing behind may be 
twisted into a rope, in which form they are less likely to 
be torn off and left behind. 



100 OBSTETRIC SYNOPSIS. 

While the placenta is being removed and for some 
time afterward the hand should hold the fundus in its 
grasp, gentle friction being meanwhile made to secure 
firm contraction and the expulsion of all clots and shreds 
of membrane. After its removal the placenta should be 
carefully examined ; if none of the uterine surface is 
missing, and the clonble layer of membranes is present, 
the uterus is known to be empty, at least so far as these 
are concerned. The perineum should also be examined, 
and any extensive laceration immediately sewed up. 

After removal of the soiled clothes, and when the 
uterus is firmly contracted, the abdominal bandage or 
" binder" may be applied, being used as a prophylactic 
against hemorrhage and as a support to the abdominal 
viscera. The bandage should be wide enough to reach 
from the ensiform cartilage to the trochanters ; it should 
be pinned as tightly as is comfortable, and when relaxa- 
tion of the uterus is feared a pad may be placed beneath 
it to compress the fundus ; the pad is said by some to be 
a cause of uterine displacement. 

If the uterus is firmly contracted, and the pulse has 
fallen below 100, the patient may be left and allowed to 
rest or sleep. 

5. ANAESTHETICS AND ANODYNES:— 

(a) Chloroform is the anaesthetic usually employed in 
labor; it is administered at the termination of the first 
and during the second stage, just before and with the 
commencement of each pain, its use being discontinued 
when the pain is over in order that complete anaesthesia 
may not be produced. 

(b) Ether may be substituted for chloroform, but its 
action is slower and less effective ; a mixture of alcohol 



ABNORMAL LABOR. 101 

(one part), chloroform (two parts), and ether (three 
parts), is frequently employed with advantage. 

(c) Bromide of ethyl is administered as chloroform 
and with the same precautions ; while it has been speci- 
ally advocated as superior to the latter its use has not 
yet become extensive. 

(d) Chloral is the best anaesthetic during the first stage 
of labor; not only does it lessen the suffering but rigid- 
ity of the cervix is frequently overcome by it. 

(e) Morphia is sometimes used instead of chloral; in 
cases of normal labor at full term its use is not advisable. 

(/) Cocaine muriate, in solution or in the form of an 
unguent (10 to 20 per cent.), applied to the cervix, vagina, 
and vulva will frequently lessen the severity of the suf- 
fering. 

The disadvantages which in varying degrees attend 
all forms of anaesthesia during labor are : prolonged 
labor on account of diminished contractions or pains; 
post-parium hemorrhage. 



CHAPTER IY. 
ABNORMAL LABOR. 

The causes which render labor abnormal are two : 
maternal; foetal. 

I. MATERNAL CAUSES.— The maternal causes of 
abnormal labor are as follows : — 

Excess of uterine force; deficiency of uterine force; 
abnormalities of the sexual organs; tumors; anomalies 
of the pelvis. 

(a) Excess of uterine force, although it is not always 
followed by unfavorable results, exposes the mother to 



102 OBSTETRIC SYNOPSIS. 

the clangers of lacerations of the cervix, vagina, and 
perineum, prolapse of the uterus from incomplete dila- 
tation, uterine inertia with hemorrhage and syncope; 
the amniotic liquor having been early discharged, the 
cord may be compressed; the child having been sud- 
denly and unexpectedly expelled may be injured by 
falling upon the floor; the traction thus made upon the 
cord may rupture it or cause inversion of the uterus. 

Treatment. — The patient should lie on her left side 
and avoid all efforts at bearing down; rupture of the 
membranes should be retarded; counter-pressure maybe 
made upon the presenting part while anodj T nes or anaes- 
thetics are administered. 

(b) Deficiency of uterine force. Weak and inefficient 
pains result from undue resistance of the soft parts, ex- 
haustion, uterine innervation, excessive uterine disten- 
sion, malposition of the uterus, a full bladder, a loaded 
rectum, death of the foetus, premature rupture of the 
membranes, or mental impressions, especially of un- 
pleasant character. 

When the contractions are inadequate on account of 
undue resistance of the soft parts they are for a time 
more vigorous in their action and more painful ; if, 
however, the obstacle be not overcome they may assume 
tetanic action or become feeble and cease altogether — 
the latter condition being known as "uterine inertia." 
Deficiency of uterine force is attended by greater dan- 
gers to the mother and child in the second stage of labor 
than in the first, and after than before rupture of the 
membranes; inertia occurring in the third stage is more 
dangerous to the mother than in the first and second 
stages. 



ABNORMAL LABOR. 103 

Treatment. — The treatment of this condition varies 
according to the cause. If the inefficient contractions 
are attended by excessive suffering, as is often the case, 
chloral or morphia may be given ; if there is innervation 
of the uterus the position should be frequently changed, 
while hot vaginal douches and rectal injections may be 
employed together with hot drinks ; if there is antever- 
sion an abdominal bandage may be applied, and the 
patient kept on her back; if there is excessive disten- 
sion the membranes may be ruptured provided there is 
a certain amount of dilatation w r ith relaxation of the 
soft parts. Artificial dilatation of the os may be ef- 
fected and followed by application of the forceps. 

Quinine and ergot may be used to stimulate the 
uterine contractions; the former has been found safe and 
harmless wiiile the latter should be used with caution, 
being never given in the first stage of labor nor in the 
second unless there is no obstruction and an earl}' de- 
livery is certain to be accomplished by a restoration of 
the normal uterine force. Faradization has been suc- 
cessful in the hands of some. 

Manual pressure upon the fundus and body of the 
uterus at the commencement of the contraction and 
while it lasts increases its force and is perfectly safe to 
mother and child, if practiced with care when nothing 
but inertia interferes with delivery. 

(c) Abnormalities of the sexual organs : — 

(1) Atresia of the generative tract, — of the vulva, 
vagina, and cervical canal, — is not common, nor is it 
usually attended by more serious results than delay 
which, in cervical stenosis, may be considerable. 

The obstruction may be congenital or acquired, par- 
tial or complete, — the latter being always acquired. 



104 OBSTETRIC SYNOPSIS. 

Treatment. — When there is complete closure of either 
vulva, vagina, or cervical canal, puncture and dilatation 
will be required. 

(2) Rigidity of the perineum is a cause of delay in 
the second stage of labor. 

Treatment. — Hot fomentations, digital dilatation, 
and, to prevent rupture, retarding the progress of the 
advancing part. 

(3) Rigidity of the cervix at the commencement of 
labor is usualty the cause of the greater length of the 
first stage; in primiparse it is a natural condition, but 
in parous women is usually caused by inflammatory 
action resulting in induration and hyperplasia of the 
cervical tissue. 

Treatment. — Moderate rigidity in the early stage, 
when the membranes are unruptured, requires no treat- 
ment. When treatment is necessary, hot vaginal douches 
or hot baths may be employed ; but if the contractions 
are very painful, chloral should be administered. 

When the membranes are ruptured, or before, if the 
general condition of the patient demands it, artificial 
dilatation may be effected, either with the finger or fingers 
in the cervical canal, or by means of the hydrostatic 
dilator of Barnes. Smearing of the os with the extract 
of belladonna is frequently employed, but with doubtful 
effect. 

(4) Malposition of the uterus retards the progress of 
labor b} r interfering with the full force of the abdominal 
muscles and also with the contractions of the uterus 
itself. 

Treatment. — Lateral displacements are corrected by 
having the patient lie on the side opposite to that of the 
displacement. 



ABNORMAL LABOR. 105 

Anteversion and anteflexion are overcome by assuming 
the dorsal position, and applying the abdominal bandage. 
Retroversion and retroflexion rarely exist to full term 
of gestation; but when either does, the mass must be re- 
placed before delivery can be effected. 

(d) Tumors of the generative tract, or of any of the 
pelvic structures, if they be of considerable size, may 
interfere with the natural termination of labor; these 
are as follows, — oedema of the vulva, thrombus of the 
vulva, and vagina, prolapse of the vaginal walls, vaginal 
hernia, distended bladder, vesical calculus, fibroid tumor, 
ovarian tumor, encysted tumor, carcinoma. 

Treatment. — If there be oedema of the vulva, make 
punctures for the escape of the serum ; if the thrombus 
be large, turn out the clot and control the hemorrhage 
by pressure or applications of MonsePs solution of iron. 

If the bladder be distended, use the catheter; if there 
be an impaction of the rectum, an enema should be given. 
Vaginal hernia must be reduced ; vesical calculi should 
be pushed above the pelvic brim, crushed, or removed 
through the rapidly dilated urethra. 

If a fibroid be the obstruction, it should, if possible, 
be pushed up out of the way, or removed if within easy 
reach; if an ovarian cyst, the pushing of it above the 
pelvic brim or puncture are indicated ; in some cases of 
fibroid and ovarian tumors the application of the for- 
ceps, craniotomy, or even abdominal section, must be 
resorted to. 

(e) Anomalies cf the pelvis. The anomalies met with 
are, abnormally large and abnormally small pelves, and 
the varieties of the latter. 

(1) An abnormally large pelvis is not favorable to 



106 OBSTETRIC SYNOPSIS. 

normal labor; the uterus does not rise out of the pelvis 
as it should, and as a result of its pressing upon the 
pelvic contents, vesical, rectal, and circulatory disturb- 
ances are set up; malpositions, especially retroversions, 
are liable to occur; during labor expulsion is apt to be 
more rapid, causing greater risks of cervical and perineal 
lacerations. 

(2) Abnormally small pelves include the following 
varieties : — 

Symmetrically Contracted Pelvis. — A rare form, and 
one which is usually of high degree. 

Flattened Pelvis. — The most common variet}^ and 
generally due to rickets. The conjugate diameter is 
shortened while the transverse is usually normal. 

Obliquely Contracted Pelvis. — Due to anchylosis of 
the sacro-iliac joint, associated with upward pressure 
upon the acetabulum of the same side, also to lateral 
spinal curvature. 

Transversely Contracted Pelvis. — The contraction 
being at the brim or at the outlet. Contraction at the 
brim is a rare deformity; contraction at the outlet is one 
of the most common. This variety of contraction is 
generally due to osteo-malacia. 

Masculine pelvis is found in muscular women ; the 
bones resemble those of the male, and the cavity is pro- 
gressively narrowed from above downward, having the 
appearance of a funnel. 

Most of the deformities mentioned, and others too 
irregular for classification, may be produced by the fol- 
lowing affections of the spinal column : — 

Spondylolisthesis (a slipping forward of the fourth and 
fifth lumbar vertebrae), by which the antero-posterior 
diameter of the inlet is diminished. 



ABNORMAL LABOR. 107 

Lordosis (a forward bending of the spine), which 
may diminish the conjugate diameter. 

Scoliosis (a lateral bending of the spine), w r hich may 
diminish the oblique and antero-posterior diameters of 
the inlet. 

Kyphosis (a backward bending of the spine), which 
may increase the antero-posterior diameter of the inlet. 

In addition the pelvis may be deformed and its cavity 
obstructed by exostoses of the sacrum and of the other 
pelvic bones. 

The causes of these deformities may be summed up 
as follows : rickets ; osteo-malacia ; anchylosis ; spinal 
curvature ; exostosis. 

The diagnosis of pelvic deformity can only be made 
by examination and actual measurement; the history 
and appearance of the patient are valuable adjuncts. 
These measurements, as previously given, are external 
and internal. 

The external measurements, which are made with the 
ordinary pelvimeter, include the distances between the 
anterior superior spinous processes of the ilia, the dis- 
tances between the iliac crests, and the external conju- 
gate, or between the spinous process of the last lumbar 
vertebra and the upper part of the symphysis pubis. 
(See page 5.) 

The internal measurements or diameters of the true 
pelvis are more important, and at the same time more 
difficult to obtain. As it is, the true conjugate diameter, 
or the distance between the promonitory of the sacrum 
and the nearest point on the inner surface of the sym- 
plrvsis pubis, w T hich is most frequently contracted, its 
measurement is most important ; to obtain this the only 
practical pelvimeter is the hand. 



108 OBSTETRIC SYNOPSIS. 

In the latter months of pregnancy, in cases of de- 
formed pelvis, the uterus is generally situated higher 
than usual, is more movable, and, as a result, more liable 
to displacement; abnormal presentation of the foetus is 
also more likely to occur. The progress of the labor is 
slower and the contractions, on account of increased re- 
sistance, are more vigorous and painful. The dangers to 
which the mother is exposed are exhaustion from exces- 
sive uterine action, contusions of the uterus, cervix, and 
vagina which may result in sloughing, and the risks of 
the various operations which may be necessary. 

The prognosis for the child is unfavorable; the caput 
succedaneum is large; the contusions of the scalp may 
end in suppuration; the cranial bones are generally- 
greatly overlapped, and internal changes are likely to 
occur. 

If the deformity is not great, if the head is of small 
or of medium size and compressible, and if the presen- 
tation is favorable, labor is most likely to be terminated 
naturally by moulding of the head. 

Treatment. — The management varies according to 
the following conditions, which should always be taken 
into account: The amount of deformity; the size of the 
foetus ; the age of the foetus. 

When the deformity has been discovered in time, pre- 
mature labor or even abortion should be induced. Asa 
rule, "if the conjugate diameter is less than three inches, 
and the transverse less than four inches, a living child 
of normal size cannot pass through the pelvis." 

In the majority of cases, however, the amount of 
deformity is slight, so that a favorable termination may 
be expected. 



ABNORMAL LABOR. 109 

When delivery cannot be effected without assistance, 
and the measurements are above those just given, the 
choice of treatment lies between the forceps and version. 
Each of these has its advantages and disadvantages ; as a 
rule, the forceps are indicated in the slighter degrees of 
contraction, version in the greater. 

If the conjugate measures less than three inches, but 
more than one and a half inches, the choice of treatment 
lies between embryotomy and Csesarean section or one 
of its substitutes, embryotomy always having the pre- 
ference. If the conjugate measures one and a half 
inches or less, abdominal section must be performed. 

2. FCETAL CAUSES. — The foetal causes of abnor- 
mal labor are as follows : Malpresentations ; great size 
of the foetus ; multiple pregnancies; extra-uterine preg- 
nancies; death of the foetus. 

{a) Malpresentations may be enumerated as follows : 
Occipito-posterior positions; lateral obliquity of the 
head; face presentations; brow presentations; pelvic 
presentations ; transverse presentations ; complicated 
presentations. 

(1) Occipito-posterior positions are the result of 
failure of forward rotation of the occiput in the third 
and fourth positions of vertex or occiput presentations. 

As a rule the head is well flexed, and as the occiput 
advances the resistance which it meets posteriorly pushes 
it forward under the pubic arch where there is more space 
and a better provision for its expulsion ; the amount of 
internal rotation is thus greatly increased, and the posi- 
tion becomes the first or second. 

This rotation fails in some cases, generally on account 
of deficient flexion of the head ; delivery is then effected 
10 



110 OBSTETRIC SYNOPSIS. 

by movement of flexion instead of the ordinary exten- 
sion ; the fronto-occipital diameter being substituted for 
the sub-occipito-bregmatie, delivery is attended with 
greater difficulty and with greater risks to the perineum. 
Artificial delivery may be necessary. 

(2) Lateral obliquity of the head, called " Naegele 
obliquity," is a rotation of the head on its anteropos- 
terior axis so that one parietal bone lies deeper in the 
pelvis than the other. It is not, as was formerly thought, 
a regular occurrence, being only found when the head 
and pelvis are disproportionate in size. 

In some cases the head may be so inclined that an 
ear can be felt; as a rule, conversion is effected without 
assistance ; but this failing, the head should not be al- 
lowed to remain in its position longer than a few hours 
after discharge of the waters. 

(3) Face presentations, as has been said, are unfavor- 
able to the child; labor is, however, in these cases gene- 
rally completed naturally. 

When the chin rotates to the front and the contrac- 
tions are strong, no interference or assistance is required ; 
when the rotation fails, attempts to effect it may be made 
with the fingers or with the short straight forceps ; if the 
head has not advanced too far the occiput may be brought 
down or version performed. 

(4) Brow presentations are usually spontaneously 
converted into face or vertex presentations by the oc- 
currence of extension or flexion. 

Pressure should be made upward during the pains in 
order that one of these presentations ma}^ be secured ; 
unless the presentation changes or is changed, natural 
delivery cannot be effected. 



ABNORMAL LABOR. Ill 

(5) Pelvic presentations in the majority of cases ter- 
minate naturally without special difficulty, but are at- 
tended with greater risks to the child. 

In these cases interference with the natural process 
is often a cause of difficulty. The early rupture of the 
membranes should be avoided ; traction should not be 
made on the presenting or partially born breech until 
the arms are delivered, as they may thus be extended 
above the head. 

When the body is partially expelled the umbilical 
cord should be placed in the most roomy portion of the 
pelvis that the pressure upon it may be lessened, mean- 
while its pulsations should be carefully noted. 

If the arms are not delivered, being extended above 
the head, the child's body should be carried well up to 
the mother's abdomen; then, if the shoulders are within 
reach the fingers may be slipped over the posterior one 
until the elbow and forearm are grasped and made to 
sweep over the face and chest of the child, thus using 
the natural movements of the joints and avoiding the 
possibility of fracture which might result from their 
being drawn directly downward. By carrying the 
child's body in the opposite direction the other arm 
may be released by a similar manoeuvre. 

If delivery of the head now seems to be too long 
delayed it ma}^ be aided or even effected by traction 
on the trunk, pressure per rectum, or pressure through 
the abdominal walls, the child's body having been carried 
well up toward the abdomen of the mother. 

If there be much delay the child must perish ; so 
that should these means of delivery prove ineffectual 
the forceps must be applied. 



112 OBSTETRIC SYNOPSIS. 

Occasionally, in third and fourth positions of the 
breech, the sacrum fails to rotate to the front ; in such 
cases before the birth of the head there is usually no dif- 
ficulty. If, however, after expulsion of the trunk, rota- 
tion of the occiput forward do not occur, the trunk 
should be drawn backward that the face may sweep 
under the pubis ; if there be extension of the head and 
if the chin hitch on the pubis the trunk should be drawn 
forward and upward that the vertex may sweep over the 
perineum. 

It may be necessary to apply the forceps. When 
there is impacted breech a foot should be brought down, 
or if this be impossible the index finger or fillet may be 
slipped over the groin and traction thus made. In such 
cases an anaesthetic will be found necessary. As a last 
resort embryotomy is justifiable. 

(6) Transverse presentations are rarely terminated 
naturally ; in these cases one of the shoulders is sooner 
or later engaged in the pelvis, and an arm may pro- 
trude. 

In rare cases delivery is effected by spontaneous 
evolution; sometimes spontaneous version occurs, but 
neither of these means of delivery can be relied on. As 
soon as possible, therefore, version should be performed. 

(*7) Complicated presentations include displacements 
of limbs, prolapse of limbs, alone or with the presenting 
part, and prolapse of the umbilical cord. 

Dorsal displacement of the arm, in which the fore- 
arm of the child becomes thrown across and behind the 
neck, may occur in presentations of the head or of the 
pelvis. In the former case the diagnosis is difficult, but 
being made out it is recommended either to bring down 



ABNORMAL LABOR. 113 

the arm or to perform version ; when the pelvis presents 
the body, as soon as it is delivered, should be carried 
well backward that the finger may pass behind the sym- 
physis and over the shoulder to liberate the arm. 

The upper extremities more frequently prolapse than 
the lower. A hand or foot may present with the head, 
or a hand may descend on each side of the head; a 
hand or arm may descend with the pelvis, or a foot and 
hand ma} r present simultaneously with this part. 

During the intervals between the pains the displaced 
members should if possible be pushed up; when the 
foot and hand present together traction should be made 
on the foot until the breech comes down and the arm 
ascends ; the possibility of a transverse presentation is 
thus prevented. 

Prolapse of the umbilical cord is favored by malpre- 
sentations or malpositions, on account of the presenting 
part not accurately fitting the pelvic brim ; excess of 
amniotic liquor ; early or sudden rupture of the mem- 
branes ; smallness of the foetus; multiparity; great 
length and weight of the cord ; placenta praevia ; and 
prolapse of the members. 

If the cord be subjected to pressure for a length of 
time its circulation is interfered with, and the child's 
death is a result. The treatment indicated is to relieve 
the pressure, and, if possible, restore the cord to its 
natural position. 

This may be accomplished by pushing the cord up 
and past the presenting part, between the pains, with 
the fingers. The patient being placed on her hands and 
knees with the hips elevated and the shoulders on a 
lower level, the cord is more readily replaced. Some 

10* 



114 OBSTETRIC SYNOPSIS. 

times it will slip back by its own weight into the uterus 
along its anterior wall which forms an inclined plane. 

After replacement the presenting part should be 
firmly engaged in the brim by pressure over the uterus, 
after which the patient should lie on her left side with 
the hips elevated. 

Various instruments are used to replace the cord. A 
simple one is improvised by holding the prolapsed cord 
with a loop of string passed through a catheter and 
emerging from its eye ; the cord may thus during the 
interval between the pains be pushed above the present- 
ing part and the instrument withdrawn. If the pulsa- 
tions in the cord have ceased, no treatment will be neces- 
sary. 

(b) Great size of the foetus is a frequent cause of pro- 
longed and difficult labor. The increase in foetal size 
depends on one or more of the following conditions : — 

Uniform enlargement of the entire body ; excessive 
development of a particular part ; hydrocephalus ; hy- 
drothorax, ascites, and retention of urine; tumors; 
monstrosities. 

(1) Uniform enlargement of the entire body, although 
it may cause delay, does not, as a rule, require artificial 
delivery. 

(2) Excessive development of the head, apart from 
hydrocephalus, with premature ossification and closure 
of the sutures and fontanelles, renders it incompressible 
and makes the application of the forceps necessary to 
effect delivery. When such a condition is suspected 
premature labor may be induced. 

A similar condition of the chest and shoulders may 
give rise to difficulty or endanger the perineum. 



ABNORMAL LABOR. 115 

(3) Hydrocephalus is an accumulation of serum in the 
cranial cavity by which the head is greatly enlarged. 
In these cases the pelvis usually presents, but even when 
the head presents the diagnosis is difficult. 

The prognosis for the child is most unfavorable, 
especially if dystocia result. The treatment consists in 
lessening the size of the head ; this may be done by 
puncture with a fine trochar, thus permitting the fluid 
to escape. 

The forceps may be applied, but there is great danger 
of their slipping. These means failing, perforation should 
be performed and delivery effected by traction on the 
head or by poclalic version. 

In pelvic presentations of such cases, if delivery can- 
not be effected by traction and supra-pubic pressure, 
perforation will be necessary although difficult to ac- 
complish. 

(4) Hydrothorax, ascites, and retention of urine 
sometimes exist before delivery with which they may 
interfere ; the treatment is puncture with a trochar or 
aspirator and evacuation of the fluid; for the removal of 
retained urine the catheter must be used. 

(5) Tumors of the foetus, such as encephaloid, spina- 
bificla, fibroids, cysts, and fibrocystic developments of 
the various organs may prevent natural delivery. 

The treatment consists in evacuation or removal, as 
the case may require. 

(6) Monstrosities may be single or double ; of each 
kind there are numerous varieties. Of the cases on 
record the majority were delivered naturally and with- 
out much trouble. It is claimed by some that labor in 
these cases is generally premature or that the children 



116 OBSTETRIC SYNOPSIS. 

have been dead for some time and are therefore of small 
size, which may account for the large number of natural 
deliveries. 

(c) Multiple pregnancies are rarely terminated by 
difficult labor ; as a rule the presence of a second foetus 
is not suspected until after the birth of the first, when the 
uterus is found to be nearly as large as it was before. In 
the majority of cases both children present by the head ; 
next in frequency is the head of one and the breech of 
the other; in a few cases both breeches present. 

There is usually some delay in the birth of the first 
child from interference with the normal uterine action 
by over-distension or unfavorable presentation. 

After the birth of the first child there is usually a 
cessation of the pains for a quarter of an hour or more; 
during this interval the cord should be tied and cut, care 
being taken to tie the placental as well as the foetal end. 

The pains generally recur in about twenty minutes 
T\hen the second child is quickly delivered, after which 
the two placentae are expelled in the ordinary wa}\ 

Should delay occur in the expulsion of the second 
child, uterine action may be stimulated by pressure and 
friction over the uterus, and by the administration of 
ergot ; the membranes should be ruptured as soon as 
they are within reach; if there is a malpresentation, ver- 
sion can be easily performed ; or if the head is engaged 
in the pelvis, the forceps should be applied. The uterus 
having been over-distended is liable to inertia, conse- 
quently there is danger of postpartum hemorrhage; on 
this account the birth of the second child should be 
delayed rather than hurried. 

Occasionally, on account of great size of the pelvis, 



ABNORMAL LABOR. 117 

small size of the foetuses, a single amniotic sac or the 
premature rupture of the membranes, one foetus may 
interfere with the delivery of the other. When both 
heads present at the brim, one should be pushed up and 
the other brought clown with the forceps. 

When the first child presents by the breech, and is 
delivered as far as the head, the second head having 
entered the pelvis, further delivery is prevented by their 
interlocking. Attempts may be made to push back the 
second head, the patient being in the knee-chest position ; 
the forceps may be applied to the second head in order 
to drag it past the body of the first child ; the first child 
may be decapitated, thus rendering easy the delivery of 
the second, or the head of the second child may be per- 
forated and the first child delivered. 

(d) Extra -uterine pregnancies are serious complica- 
tions to mother and child ; the former may survive but 
the latter almost always perishes. The diagnosis, al- 
though difficult in the earh r months, may be made by 
•careful examination ; the uterus is found enlarged but 
displaced ; there is less cervical softening ; the signs of 
pregnancy are present but the uterus does not enlarge 
after the third or fourth month ; attacks of abdominal 
pain may occur; if they are due to rupture of the tube 
the attacks m;iy be accompanied by collapse and signs of 
internal hemorrhage. 

There is still doubt about the proper management of 
these cases. During the early months foetal life has in 
some cases been destroyed by electricity, but at this 
period abdominal section with removal of the cyst and 
its contents is probably the best procedure. In the latter 
half of pregnancy, before death of the foetus, the results 



118 OBSTETRIC SYNOPSIS. 

of abdominal section have been almost invariably fatal ; 
if the operation be delayed until after the foetus is dead, 
on account of obliteration of the placental circulation, 
the mother's chances of recovery are increased. Where 
death of the foetus has occurred it is advisable to delay 
operation until the gravity of the mother's symptoms 
has subsided or until there is some indication of the 
channel through which the foetus will be expelled. 

(e) Death of the foetus is liable to occur at an} T period 
of gestation, but the dead foetus is not thrown off by the 
uterus until it acts as a foreign body. The time during 
which it may be retained varies from a few hours to 
several weeks. 

The indications of foetal death are, cessation of its 
movements, a feeling of coldness and weight in the 
uterine region, flaccidity of the breasts, absence of the 
heart-sounds where previously heard, impairment of the 
mother's health and offensive breath, offensive discharges 
from the uterus, and during labor a looseness of the cra- 
nial bones and absence of the caput succeclaneum. 

Labor is generally more tedious on account of torpid 
uterine action, but apart from the delay no unusual dif- 
ficulty is to be feared. 



CHAPTER V. 
COMPLICATED LABOR. 

The complications which may occur immediately 
before, during, or immediately after labor, are as fol- 
lows : Eclampsia ; placenta prsevia ; hemorrhage ; reten- 
tion of the placenta; inversion of the uterus; rupture 
and laceration of the genital canal; thrombus of the 
vagina and vulva. 



COMPLICATED LABOR. 119 

I. ECLAMPSIA, also called puerjieral convulsions, 
may occur in connection with pregnancy, labor, or the 
puerperal state. The convulsions resemble those of epi- 
lepsy, but should be distinguished from them, from hys- 
terical convulsions, and from convulsions due to brain 
lesions. They occur once in about 500 labors, and in the 
majority of cases affect primi parse ; they most frequently 
commence while labor is in progress, and are less frequent 
in the puerperal state than during pregnancy. The cause 
of eclampsia is still doubtful; as a rule, it is associated 
with renal disease, albuminuria, and suppression of urine. 

Most authorities claim that the convulsions are due 
to changes in the kidney structure which changes result 
in albuminuria, renal insufficienc} T , and the consequent 
retention of poisonous products in the blood. The urea 
thus retained is tb ought by some to be decomposed and 
to produce carbonate of ammonia, the supposed toxic 
agent according to this theory. The poison is probably 
not a single element, but made up of the various urinary 
constituents which are retained in the blood. 

Another theory is that of reflex irritation of the 
nerve centres which have an increased irritability in 
pregnancy, combined with an extreme water}^ condition 
of the blood or with retention of toxic agents in it 
(uraemia or urinaemia). It is claimed that in some cases 
the reflex irritation alone (the gravid uterus and its con- 
tents) may excite them, but that in the majority of cases 
the reflex irritation must be associated with changes in 
the kidney structure and renal insufficiency. Cerebro- 
spinal congestion was once thought to be a cause of 
eclampsia, but is now generally admitted to be a result. 

Cerebral anaemia produced by pressure of serous 



120 OBSTETRIC SYNOPSIS. 

effusion upon the small cerebral vessels has been fre- 
quently found on autopsy, and is given as a cause of the 
convulsions ; it is probable that the effusion is the result 
of the convulsions rather than the result of hydremia 
or previous increase in arterial pressure. 

Eclampsia may occur without previous symptoms, 
but is usually preceded by headache, vertigo, disturb- 
ance of vision, gastric disturbance, impairment of the 
intellect, general oedema, albuminuria, and partial or 
total suppression of urine. 

After a longer or shorter prodromal stage the attack 
sets in suddenly; it consists of two stages, that of tonic 
convulsion, that of clonic convulsion. 

The convulsions commence in the facial muscles, and 
gradually involve all the muscles of the body. There is 
complete loss of consciousness during and after the at- 
tack, the coma becoming more marked with each suc- 
ceeding one. At the commencement of the attack res- 
piration ceases; later, it is hurried and irregular. There 
is rarely a single convulsion, in some cases there have 
been more than a hundred. The pulse becomes small 
and rapid, and there is a considerable rise in temperature. 

Death usually results from carbonic-acid poisoning, 
nervous exhaustion, or a combination of asphyxia and 
exhaustion ; eclampsia predisposes to post-partum hemorr 
rhage, puerperal inflammations, and mental disturbances. 

The prognosis for mother and child is always serious, 
the maternal mortalit}^ being about thirty per cent. ; the 
earlier the convulsions occur the more unfavorable the 
prognosis. 

Treatment. — Proph}dactic treatment includes what 
has been mentioned for cases of albuminuria ; when 



COMPLICATED LABOR. 121 

cerebral symptoms begin to show themselves, bromide 
of potassium, chloral, and a hydragogue cathartic should 
be administered. When the attack comes on before 
labor, if the pulse is strong, and there seems to be 
cerebral congestion, bleeding is indicated, but it should 
not be carried to the extent of depression. During the 
attack chloroform should be administered by inhalation ; 
chloral by the mouth, if possible, or by rectal injection 
(5ss. to 5j-) should be given at intervals until it pro- 
duces a decided effect ; morphia hypodermieally (gr. ^) 
is recommended; pilocarpine, nitrite of amyl, and nitro- 
glycerine have also been tried with some success ; the 
hot bath has been recommended and successfully tried 
in a few cases. 

In a large proportion of cases the convulsions cease 
after the birth of the child. Delivery should therefore 
be hastened as much as possible without incurring addi- 
tional risks to the mother ; if eclampsia come on before 
the commencement of labor premature labor may- be in- 
duced. 

2. PLACENTA PR/EVIA is the attachment of the 
placenta at the lower segment of the uterine cavity; 
some authorities recognize four varieties as follows : 
Central, partial, marginal, and lateral; others recognize 
only two, complete or central, and incomplete or mar- 
ginal. Central attachment of the placenta is a rare 
occurrence; the marginal and lateral attachments are the 
most common. 

Placenta prsevia occurs once in about 570 labors, is 
much more frequent in multiparas than in primiparse, 
and in the poor than in the rich. 

The cause of placenta prsevia is the attachment of 
11 



1'2'2 OBSTETRIC SYNOPSIS. 

the ovum at the lower segment of the uterine cavity, 
either from its having fallen down from the usual point 
of attachment, from incomplete abortion, or from im- 
pregnation of an ovule in this situation. 

The occurrence of placenta praevia is favored by ab- 
normal size and unusual shape of the uterine cavity, 
diseased conditions ' of its mucous membrane, and spas- 
modic uterine contractions. 

The first symptom is a sudden loss of blood which 
usually occurs without warning or pain. Hemorrhage 
rarely occurs before the end of the sixth month, being 
more often nearer the full period; sometimes it does not 
come on until labor has commenced. If the hemorrhage 
come on early it may be but slight; but a recurrence is 
to be feared as it is liable to terminate fatally. If the 
hemorrhage come on when labor has commenced it may 
be excessive and have the same fatal termination. 

The blood comes from the arteries and veins in the 
uterine wall from which the placenta has been separated; 
also, from the separated placental surface. 

The cause of this separation before fall term may be 
the dilatation of the internal os, which is thought by 
some to take place during the last two months of gesta- 
tion; the rapid increase in the cervical derelopment 
toward the end of pregnancy; the partial separation of 
the placenta from accidental causes ; the rupture of a 
utero-placental vessel near the internal os; or, the rup- 
ture of a marginal utero-placental sinus. 

Hemorrhage at the commencement of labor is ex- 
plained by the dilatation of the cervix which is known to 
occur at this time. 

When the placenta has been completely detached, or 



COMPLICATED LABOR. 123 

after separation of the membranes, or when the present- 
ing part comes clown and presses upon the open vessels, 
the hemorrhage ceases, the prognosis for mother and 
child is unfavorable. Of the former about 25 per cent. 
die, of the latter about 50 per cent. 

Malpresentations are common in placenta prsevia on 
account of the large size of the uterine cavity, the fre- 
quent occurrence of premature labor, and because the 
placenta prevents the head occupying the lower segment 
of the uterus. 

Treatment (Play fair). — "When a sudden hemorrhage 
occurs in the latter months of pregnancy placenta praevia 
should be suspected and a careful vaginal examination 
made. Before the child has reached a viable age tempo- 
rize, provided the hemorrhage is not excessive, until 
pregnancy has advanced sufficiently to afford a reason- 
able hope of saving the child. 

For this purpose the chief indication is absolute rest 
in bed, to which other accessory means of preventing 
hemorrhage, such as cold, astringents, etc., may be 
added. 

In hemorrhage occurring after the seventh month of 
utero-gestation no attempt should be made to prolong 
the pregnancy. 

In all cases in which it can be easily effected the 
membranes should be ruptured. By this means uterine 
contractions are favored and the bleeding vessels com- 
pressed. 

If the hemorrhage has stopped, the case may be left 
to nature. If, however, the flooding continue, and the 
os be not sufficiently dilated to admit of the labor being 
readily terminated by turning, the os and the vagina 



124 OBSTETRIC SYNOPSIS. 

should be carefully plugged, while uterine contractions 
are promoted by abdominal bandages, uterine compres- 
sion, and ergot. The plug must not be left in beyond a 
few hours. 

If on removal of the plug the os be not sufficiently 
expanded, and the general condition of the patient be 
good, the labor may be terminated by turning, the bi- 
polar method being used if possible. If the os be not 
open enough, it may be advantageously dilated by 
means of a Barnes' bag, which also acts as a plug. 

Instead of or before resorting to turning the pla- 
centa may be separated around the site of its attachment 
to the cervix. This practice is specially to be preferred 
when the patient is much exhausted and in a condition 
unfavorable for bearing the shock of turning. 

3. HEMORRHAGE may occur before or after delivery, 

(a) Hemorrhage before delivery may be due to pla- 
centa pr&via, or it may be accidental. 

Accidental hemorrhage is due to the separation of a 
normally situated placenta ; the blood may find exit be- 
tween the membranes and decidua, or it may collect 
within the uterus and give rise to " concealed hemor- 
rhage." 

Accidental hemorrhage rarely occurs to an alarming 
extent until the latter months of pregnancy. 

The causes are : direct violence ; a fall or shock ; ex- 
cessive muscular exertion ; unusually strong uterine con- 
tractions. Diseased conditions of the uterus, membranes, 
and placenta, such as would produce hemorrhage and 
abortion in the earlier months, may cause the placental 
separation and consequent hemorrhage; on this account 
the accident rarely happens to primiparse and those in 



COMPLICATED LABOR. 125 

good health. When the blood escapes from the vagina 
the condition of affairs is readily made out ; if the hemor- 
rhage be concealed it may continue undetected until 
alarming symptoms of collapse set in. 

The prognosis for mother and child is always bad ; 
when the hemorrhage is concealed the mortality to both 
is still greater. 

Treatment. — The membranes should be ruptured as 
soon as possible; in cases of slight hemorrhage this alone 
may control it, but in order to guard against concealed 
hemorrhage a firm abdominal binder should be applied. 
If the hemorrhage continue uterine contractions may be 
excited by friction or by the use of ergot; the os should 
be dilated, and if delivery cannot be quickly effected the 
forceps or version must be emplo} T ed. 

(b) Hemorrhage after delivery (post-partum hemor- 
rhage) may occur during the third stage of labor, shortly 
after its completion, or after an interval of days or weeks. 

The causes of post-partum hemorrhage are : failure of 
or interference with the formation of thrombi in the 
veins; lacerations of the cervix, vagina, and perineum. 

Uterine inertia is a result of protracted labor, pre- 
cipitate labor, over-distension of the uterus from twins 
or excessive amniotic liquor, hemorrhage before delivery, 
or exhaustion. 

Contraction of the uterus may be hindered b} T re- 
tained placenta (all or a part), clots, shreds of mem- 
brane, peritoneal adhesions, or tumors. 

Formation of thrombi is prevented by sudden move- 
ments, straining, coughing, etc. 

Hemorrhage occurring a considerable time after labor 
is due to an atonic condition of the uterus produced by 

11* 



126 OBSTETRIC SYNOPSIS. 

the presence of clots, shreds of membrane, or pieces of 
placenta in the uterine cavity, or to expulsion of 
coagula in the mouths of the vessels by suddenly rising, 
by exertion and straining, by stimulants, displacements 
of the uterus, inversion of the uterus, laceration of the 
cervix, thrombi, and fibroid tumors. 

The hemorrhage may commence immediately after 
the birth of the child and before the expulsion of the 
placenta ; in this case it is due to partial or entire sepa- 
ration of the placenta not accompanied by uterine con- 
traction. It may commence gradually or suddenly, and 
in some cases is concealed. Before and after the hemor- 
rhage there is usually a marked frequency of the pulse, 
and the hard uterine tumor cannot be felt through the 
abdominal wall. The loss of blood may be great and 
the S}^mptoms threatening, but recovery generally takes 
place. 

Treatment. — Post-part urn hemorrhage may be pre- 
vented by keeping up continuous uterine contraction 
after delivery; after the birth of the child the condition 
of the uterus should be carefully watched, the contracted 
fundus being continually under the grasp of the hand. 
Care should be exercised in removal of the placenta that 
none of it is left behind, that the membranes come 
away, and that all clots are expelled. If for any reason 
flooding is to be feared a full dose of ergot should be 
administered shortly before the birth of the child if there 
is every indication that delivery will shortly be effected; 
the abdominal binder should not be applied for a consider- 
able time after expulsion of the placenta, nor until the 
uterus is firmly contracted; the patient should be care- 
fully watched until the pulse has returned to its natural 
state or is below 100. 



COMPLICATED LABOR. 127 

When the hemorrhage occurs prompt treatment is 
necessary ; the two indications are: production of uterine 
contractions; production of thrombi in the vessels. Of 
these, the first is the safer as well as the more effective 
method. If bleeding commence before the placenta is 
expelled, pass the hand gently into the uterus and clear 
it of its contents. If the bleeding continue after the 
placenta has been removed, or after its expulsion, place 
the patient on her back and grasp the fundus and body 
of the uterus with the hands, making compression and 
friction until contraction has been secured. The bi- 
manual method of compression (one hand in the vagina, 
the other upon the abdomen | is very effective. 

These means failing, pass the hand into the uterus 
and remove any clots, shreds of membrane, or pieces of 
placenta that may remain. Ergotin should be adminis- 
tered hypodermically. The uterus may be stimulated 
to contract by the application of cold; ice or ice-water 
may be applied to the abdomen and in the vagina, or in 
the uterus itself. 

If the cold applications fail, and the patient is ex- 
hausted, hot water ( 110 3 , or as hot as the hand can bear) 
may be injected into the uterus. 

The application of the child at the breast will some- 
times, by reflex action, excite uterine contraction. 

When these means fail styptic injections should be 
used ; of these Monsel's solution of iron 1 1 part to 4 
or 6 parts of water) may be injected into the uterus or 
applied directly to the bleeding surface with the ordinary 
uterine applicator. Tincture of iodine is recommended 
for the same purpose. In an emergency, vinegar is a 
g;ood substitute fur either. 



128 OBSTETRIC SYNOPSIS. 

Hemorrhage arising from laceration of the soft parts 
may be checked by compression or by application of the 
st}^ptic solution. 

The alarming symptoms which may result from the 
excessive loss of blood should be counteracted by lower- 
ing the head and elevating the lower extremities ; ether 
or brandy should be subcutaneously injected (r^xx. to 
lx.), or a large dose of laudanum (n^xxx. to lx.) may 
be given, the dose being repeated if necessary; the ex- 
tremities should be bandaged, and, in extreme cases, 
transfusion of blood may be the only means of preserv- 
ing life. 

Under no circumstannes should a vaginal or uterine 
tampon be used, as the escape of the blood externally 
would only be prevented, while a fatal concealed hemor- 
rhage might be going on within the uterine cavity. 

In secondary post-part urn hemorrhage a careful 
vaginal examination should be made, and, if possible, 
the interior of the uterus should be explored. The 
cavity should be thoroughly emptied, ergot should be 
given, and the patient kept perfectly at rest ; if the hemor- 
rhage continue, iodine or the styptic solution of iron 
may be applied to the interior of the uterus. 

4. RETENTION OF THE PLACENTA may be due 
to uterine inertia, to large size of the placenta itself, to 
separation of its central portion by traction on the cord, 
to morbid adhesions due to a previous endometritis, or 
to the so-called " hour-glass contraction" of the uterus. 

The immediate danger is postpartum hemorrhage; if 
the placenta has been retained for some time septic 
poisoning may result. 

Treatment. — As Ions; as there is no hemorrhage the 



COMPLICATED LABOR. 129 

natural expulsion of the placenta can be awaited or 
Crede's method may be employed ; some traction may 
be made on the -cord, but as soon as the lower margin of 
the placenta is within reach it should be grasped and the 
entire mass drawn gently downward. If, after waiting 
a considerable time, or if hemorrhage occur and the 
other means of expression have failed, the fingers and 
hand should be passed into the uterus, and, the fingers 
having been gently inserted between the placenta and 
the uterine wall, the entire mass quickly stripped off and 
brought down, external pressure upon the abdomen 
having been continuously made with the other hand. 

If there is any " hour-glass contraction " it should be 
gradually dilated with the fingers, after which the pla- 
centa may be removed. 

In the artificial separation of the placenta care must 
be taken that none of it has been left within the uterus, 
and that all the membranes have been brought away. 

The passage of the hand within the uterus increases 
the risks of septic poisoning. The hand, therefore, 
should be thoroughly aseptic, and it is recommended 
that the uterus be washed out afterward with a disin- 
fectant solution. 

5. INVERSION OF THE UTERUS is a partial or 
complete turning inside out of the organ. It may be 
produced either before or after the expulsion of the 
placenta, and is of rare occurrence. 

Inversion of the uterus is favored by uterine inertia 
and attachment of the placenta exactly at the fundus, 
but the immediate causes usually are, pressure upon the 
fundus or traction on the cord when the uterus is re- 
laxed ; sometimes it is due to weight of the placenta, or 
it may occur spontaneous!}^. 



130 OBSTETRIC SYNOPSIS. 

The symptoms of inversion are : hemorrhage due to 
the inertia, and shock which is evidenced by a small 
pulse, cold extremities, and vomiting. 

The diagnosis is made tty vaginal examination, by 
absence of the uterine tumor above, and by the conjoint 
manipulation. 

Treatment. — The inverted portion should be imme- 
diately grasped in the hollow of the hand and pushed 
gently and firmly upward in the direction of the pelvic 
axis, counter-pressure being made upon the abdominal 
walls. If the placenta is attached or only partially ad- 
herent, it may be stripped off before the reduction is 
made; if, however, it is completely adherent and there 
is no hemorrhage, it may be allowed to remain until the 
organ is restored to its natural condition. 

If contraction of the cervix prevents reduction, and 
the condition of the patient will allow, an anaesthetic 
should be given. In some rare cases, after all attempts 
have failed, spontaneous restoration has occurred. 

6. RUPTURES AND LACERATIONS OF THE 
GENITAL CANAL include rupture of the uterus, lacera- 
tions of the cervix, lacerations of the vagina, lacerations 
of the vulva and perineum. 

(a) Rupture of the uterus is a rare but most danger- 
ous accident of labor; it may take place at any part of 
the uterus, but is most common at the junction of the 
cervix with the bod}\ The rupture is usually vertical 
and located in the anterior or posterior wall; it may 
involve both the uterus and peritoneum, the uterus alone 
or the peritoneum alone, or it may extend downward and 
involve the vagina. 

The causes of rupture are : predisposing, exciting. 



COMPLICATED LABOR. 131 

The predisposing causes are alterations of the uterine 
tissue,— such as are produced by the presence of fibroids, 
carcinoma, fatty degenerations of the muscular fibres, 
excessive thinning of the uterine walls, obliteration of 
the os, rigidity^ of the cervix, and the changes produced 
by former labors, — deformed pelvis, large size of the 
foetal head, malpresentations, and any condition which 
produces undue compression or stretching of any part 
of the uterus. 

The exciting causes are : blows, falls, injury by instru- 
ments, and excessive uterine action such as occurs in 
contracted pelvis, and after the use of ergot. 

Rupture usually occurs suddenly, and is accompanied 
by great pain in the abdomen, and a feeling that some- 
thing has given way. The uterine contractions usually 
cease ; vaginal examination reveals hemorrhage and a 
change in the presentation or position. 

If the child has escaped into the peritoneal cavity the 
form of the abdomen is changed, and the foetus can be 
felt beneath the abdominal wall. Symptoms of hemor- 
rhage and collapse soon set in, and the patient usually 
dies. 

Treatment. — Rupture should be prevented by the 
avoidance of ergot and undue exertion ; when pressure 
and stretching of the uterus have been of considerable 
duration, interference in the way of artificial delivery is 
indicated. If rupture has occurred, and the foetus is 
still in the uterus, rapid delivery should be effected 
either with the forceps or by version. 

If the entire foetus or a greater part of it has escaped 
from the uterus and passed into the peritoneal cavity, the 
operation of gastrotomy affords the mother the best 



132 OBSTETRIC SYNOPSIS. 

chance of recovery. This should not be undertaken 
until she has rallied from the effects of the shock which 
may be overcome with stimulants. 

(b) Lacerations of the cervix are of very common 
occurrence. The lacerations are generally lateral, either 
on one or both sides ; they may extend in a vertical direc- 
tion or be stellate ; in rare cases an entire ring of cervical 
tissue has been detached. These lacerations are the re- 
sults of rigidity combined with undue expulsive force or 
of artificial delivery of the child. Premature rupture of 
the membranes predisposes to laceration, and pressure 
of the anterior lip of the cervix between the head and 
pubis may cause it. They may be followed bj- postpar- 
tum hemorrhage (primary or seconda^), septicaemia, 
pelvic inflammations, or chronic uterine disease. 

Treatment. — The hemorrhage may be checked by 
the application of ice, by cold or hot water injections, 
or by the application of Monsel's solution of iron. In 
severe forms of laceration the immediate application of 
sutures is recommended. 

(c) Lacerations of the vagina may be mere abrasions 
of the surface, or they may extend entirely through the 
wall. 

Abrasion and sloughing may result from prolonged 
pressure of the head, and end in perforation of the wall 
with the establishment of vesico-vaginal or recto-vaginal 
fistula, or the injury may be produced by instrumental 
delivery. 

Treatment. — Sutures will rarely be required. Hemor- 
rhage may be arrested by cold or heat, by pressure, or 
by the application of styptics. Cleanliness is an essen- 
tial part of the treatment. 



COMPLICATED LABOR. 133 

(d) Lacerations of the vulva and perineum. The 

Vaginal outlet formed by the insertion of the hymen is 
almost invariably ruptured in first labors, the tear ex- 
tending to the base of the hymen and reaching the cellu- 
lar tissue of the vaginal wall. The lacerations may 
involve the perineal body and extend up to the sphincter 
ani. or even through the sphincter into the rectum. 

Treatment. — Prophylaxis has been mentioned in con- 
nection with the management of normal labor. 

Hemorrhage may be arrested by the usual means. 
If the laceration is slight, rest and cleanliness will suf- 
fice ; if it is more extensive, the surfaces must be brought 
together by sutures as soon as the placenta has been 
removed, and the patient kept in bed with her knees 
together. The urine should be drawn off with a catheter 
for a day or two, after which it may be passed while the 
patient is in the kneeling or knee-and-elbow position. 
The sutures should be removed in about a week. 

7. THROMBUS OF THE VAGINA AND VULVA is 
an effusion of blood into the cellular tissues ; it may 
occur during pregnancy, but is most common during or 
immediately following labor. 

The hemorrhage may be arterial or venous — gene- 
rally of the latter origin — and although usually situated 
in one of the labia it may extend along the vagina to the 
pelvic cellular tissue. The tumor may become as large 
in size as a foetal head. 

The conditions favoring thrombus are : Engorgement 
and distension of the vessels due to pregnancy or to 
interference with the return of blood by pressure of the 
head during labor; the violent efforts of the patient. 

The symptoms are : Pain of a tearing character; a 
12 



134 OBSTETRIC SYNOPSIS. 

firm, hard swelling if the effusion has taken place in 
the external parts. 

The tissues are lacerated, and the swelling ma}' be- 
come so great as to cause bursting of the skin ; fatal 
hemorrhage may ensue whether the skin has or has not 
been ruptured. 

Thrombus may terminate by absorption if the exuda- 
tion be slight, by bursting of the skin, or by suppuration. 

Treatment. — If thrombus occur during labor the 
latter should be terminated as quickly as possible, the 
forceps being applied as soon as the head is within 
reach. If the tumor is of considerable size or obstructs 
delivery, it should be freely incised at its most promi- 
nent point and the clots turned out, the hemorrhage 
being controlled by digital pressure and by filling the 
cavity with cotton saturated in Monsel's solution of 
iron. If the thrombus is small, or if it has not been 
detected until after delivery, it may be left alone, as 
absorption is most likely to occur ; if it should suppu- 
rate, the abscess must be opened and the wound treated 
antiseptically. 



PART V. 

THE PUERPERAL STATE. 



CHAPTER I. 
PHYSIOLOGY OF CHILDBED. 

The puerperal state includes a period of about six 
weeks, commencing immediately alter labor and con- 
tinuing until the uterus has undergone the process of 
involution. 

After labor the patient may experience a sense of 
comfort and repose, but there is usually a temporary 
condition of exhaustion or nervous depression which 
may be followed b} r a chill of greater or less intensity, 
but of short duration and of no significance. 

The temperature during labor, and for a short time 
after, is slightly elevated ; it may remain stationary or 
rise somewhat until lactation is established, but gene- 
rally commences to decline within the first twenty-four 
hours. A temporary rise of temperature, occasioned by 
excitement, constipation, or error of diet, is liable to 
occur at any time; but unless it continues above 100°, 
and is associated with rapidity of the pulse, nothing is 
to be feared. 

The pulse, which was more rapid during labor, is 
diminished in frequency, and may even for a time sink 
below the normal ; this slowing of the pulse is a favor- 
able indication, and should be looked for in all cases. 

(135) 



136 OBSTETKIC SYNOPSIS. 

A temporary increase in frequency is of common occur- 
rence. 

The secretions are generally more active, especially 
those of the skin and kidneys ; on this account, and be- 
cause of the changes in the pelvic organs and the dis- 
charges from the genital canal, the loss in weight during 
the first week is nine to ten pounds. The bowels are 
constipated, and there may be retention of urine for a 
clay or two. 

After-pains, the irregular painful contractions of the 
uterus which may commence a short time after the ex- 
pulsion of the placenta and recur at various intervals 
during the first four days, are most common in multi- 
parse, after rapid delivery, or where from any cause 
uterine inertia exists. They may be excited by applica- 
tions of the child at the breast, but generally depend on 
the presence of coagula in the uterus. 

Lochia, the discharge from the genital organs espe- 
cially the uterus during the period of its involution, 
consists of blood corpuscles, epithelium, shreds of de- 
ciclua and membrane, pieces of placenta, pus cells, 
mucus, and fat. During the first few days it is alkaline 
in reaction and red in color, consisting of nearly pure 
blood which is sometimes clotted. Its appearance 
gradually changes, and at about the fifth or sixth day 
becomes a pale green ; after the eighth or ninth day the 
reaction is neutral or acid while the discharge becomes 
muco-purulent, gradually lessening in amount and chang- 
ing to the normal transparent mucus. 

The amount of the discharge varies in different 
women, but its character and appearances depend on 
the conditions of the organs, especially the progress of 
involution or the existence of cervical lacerations. 



TIIYSIOLOGY OF CHILDBED. 137 

The odor may become exceedingly offensive on ac- 
count of retention and putrefaction of coagula, pieces 
of placenta or shreds of membrane; if such a condition 
be neglected septic poisoning may result. 

The uterus immediately after delivery contracts 
firmly, and can be felt at the lower part of the abdomen 
as a hard firm mass about the size of a foetal head. 

The more complete and permanent the contraction 
the greater the safety and comfort of the patient, and 
the more rapid and favorable the process of involution. 

During the first ten days after delivery the fundus 
can be felt above the pubis, but after the second week 
the entire organ should be beneath the pelvic brim. The 
cervix is soft and patulous for some weeks after delivery. 
The mucous membrane is covered with a reddish-gray 
film of blood, fibrin, and remains of decidua, and the open 
mouths of the sinuses can be detected with their pro- 
jecting thrombi. The rapid diminution in the size and 
weight of the organ is due to a fatty degeneration of its 
muscular fibres. 

The vagina remains soft, smooth, and dilated for some 
days, and is always more lax and less rugose than 
in nulliparae. 

The secretion of milk is generally established in about 
forty-eight hours. During the latter months of pregnancy 
and immediately after labor a fluid called colostrum is 
found in the breasts ; having a larger supply of salts 
than milk it acts as a laxative for the child and assists 
in cariying off the meconium. 

The establishment of the lacteal secretion on the 
second or third day after delivery is often accompanied 
by constitutional irritation ; the breasts become swollen 

12* 



138 OBSTETRIC SYNOPSIS. 

and tender, the pulse is quickened, the temperature ele- 
vated, and there may be slight shiverings, — the disturb- 
ance being known as " milk fever." 

As soon as the secretion has been established these 
symptoms usually subside. 



CHAPTER II. 
MANAGEMENT OF CHILDBED. 

During the lying-in period the three essentials are : 
quietness, cleanliness, and rest. As soon as the uterus 
is perfectly contracted and the external parts have been 
washed in a warm antiseptic solution, the soiled clothing 
must be removed ; after the abdominal bandage has been 
applied and the patient has had what light nourishment 
she may require the room should be darkened and all 
noise or excitement removed that sleep may be induced. 
After a few hours the patient should be seen and par- 
ticular attention given to the conditions of the pulse, 
bladder, and uterus ; if there be retention of urine hot 
fomentations may be cautiously applied over the hypo- 
gastrium, but the catheter must be used before a delay 
of many hours has elapsed. The abdomen should be 
felt to ascertain that the uterus is not unduly relaxed 
or distended, and that there is no special tenderness on 
pressure. 

After-pains, if severe should be relieved by opiates, 
or if the lochia be not over-abundant by external appli- 
cations of heat. Quinine (gr. x) is recommended when 
the opiates fail. 

The diet should consist of easily digestible food, 



MANAGEMENT OF CHILDBED. 139 

such as milk, eggs, fish, chicken, essence of beef, toast, 
tea, etc. ; after the third or fourth day when the bowels 
have been evacuated and lactation is established, the 
ordinary diet may be resumed with safety, but the pa- 
tient being confined to bed does not require the same 
amount of solid food as when she is up. 

On the third or fourth day it is customary to have an 
action of the bowels, either by an enema of soap and 
water, a dose of castor-oil, or, if the secretion of milk is 
over-abundant, by a saline laxative. In the majority of 
cases the pulv. glycyrrhiza comp. is an efficient and 
agreeable remedy ; aloes in small doses is recommended 
wiien the patient has hemorrhoids. 

Cleanliness in every particular is absolutely neces- 
sary. The room should be warm, but the air must be 
kept fresh and pure. The napkins which are applied to 
the vulva to receive the flow should be frequently 
changed. The external parts should be washed at fre- 
quent intervals with a warm antiseptic solution, and 
vaginal injections of a similar warm solution are gene- 
rally used. All soiled clothing must be immediately 
removed from the chamber. If the lochia become offen- 
sive, injections of Labarraque's solution (liquor sodse 
chlorinatse) (diluted) or carbolic acid (diluted) should 
be frequently used until the unpleasant odor has disap- 
peared; these failing, the interior of the uterus must be 
cleansed, either by injections or by the use of the dull 
curette when the finger cannot be introduced. 

Rest in bed for a considerable time is an important 
part of the management; the number of days the patient 
should remain in bed depends on her condition, especi- 
ally on the progress of involution ; but the longer she 
retains the recumbent position the better. 



140 OBSTETRIC SYNOPSIS. 

If everything be favorable, after nine or ten days she 
may be permitted to sit up a little, but should avoid 
walking or any exertion for at least three or four weeks. 
During convalescence mild tonics and change of air are 
often serviceable. 



CHAPTER III. 
CONDITION AND CARE OF THE INFANT. 

A healthy child, as has been said, begins to breathe 
and to cry almost immediately after its expulsion. In 
such cases, as soon as the pulsations of the cord have 
ceased or have become feeble, the ligature is applied and 
the child given to the nurse to be washed and dressed. 

In order to facilitate the removal of the unctuous 
material (vernix caseosa) with which it is covered, the 
body should be anointed with some oil}' substance such 
as lard, sweet oil, vaseline, etc., after which it may be 
carefully washed in warm water, care being taken that 
the eyes are thoroughly cleansed and that the child is 
not too long exposed. In cool weather it is safer to 
avoid the use of water in the first cleansing; of the child 
as it is liable to take cold ; having been well anointed 
the secretions can be readily removed by soft cloths. 

The dressing for the cord usually consists of a piece 
of linen (sometimes charred) with a hole in its centre 
through which the cord is passed, the linen being then 
folded over the cord. 

Absorbent cotton has been recommended for covering 
the cord, and is probably the best dressing that can be 
applied. 

The dressing should be renewed from day to day 



CONDITION AND CARE OF THE INFANT. 141 

until the cord has withered and separated. This gener- 
ally occurs within a week, and a small pad of soft linen 
is then placed over the umbilicus. 

The child's abdomen should be supported by a flannel 
bandage which will also hold the dressing of the cord in 
place, care being taken that the bandage is not too tight. 
The child's clothing should be warm but light. 

Bathing of the entire body in tepid water is neces- 
sary at least once daily. 

The vernix caseosa. as has been said, is an unctuous 
material consisting of epithelium and sebaceous secre- 
tion which covers the skin of the child at birth. 

The meconium is a black fluid consisting of bile and 
mucous which is discharged from the bowels of the child 
during the first few days after its birth. 

The caput succedaveum is an oedematous swelling 
which forms on the head; it is produced by effusion 
from obstruction of the venous circulation caused by 
the pressure to which the head has been subjected. The 
size and situation of the swelling vary with the duration 
of labor and the position of the head. 

It usually disappears in a few days, as do other altera- 
tions in the form of the cranium, and it is only when 
suppuration has occurred that puncture or incision is 
necessary. 

The breasts of new-born children, both male and 
female, are sometimes enlarged, and on pressure will 
yield a milky fluid ; in almost all cases the secretion dis- 
appears in a few days, but if the breasts be irritated, 
suppuration may result. 

Asphyxia Neonatorum. — In man3 r cases of prolonged 
second stage of labor, the head having been subjected to 



142 OBSTETRIC SYNOPSIS. 

long-continued pressure, or the utero-placental circula- 
tion having been interfered with, the child may be appa- 
rently dead when born. 

If its pulsations have ceased the cord should be im- 
mediately tied and the child removed from the mother 
by cutting the cord beyond where the ligature has been 
applied ; but when the face is livid it is sometimes bene- 
ficial to allow a few drops of blood to escape from the 
previously severed cord before applying the ligature. 
The mucus having been cleared from its mouth by the 
fingers, respiration should be stimulated by sharp slaps 
upon the thorax with the hand or a wet towel, by 
quickly rubbing the body with brandy poured upon the 
hands, by sudden and alternate applications of heat and 
cold, or by carrying on artificial respiration by move- 
ments of the arms and chest. These means failing, a 
flexible catheter should be passed into the glottis when 
air can be gently blown into the lungs and expelled by 
compression of the thorax. The fluids which fill the 
trachea w r ill flow through the catheter, or may be sucked 
up into the instrument and thus removed from the lungs. 
The same effect may be produced by placing the hand over 
the child's nostrils and blowing directly into its mouth, 
but the liability is that the stomach will be inflated instead 
of the lungs. As long as the heart continues to act 
there is hope for recovery, and artificial respiration 
should be persevered with until the natural respiratory 
movements commence. 

Jaundice commonly occurs a few days after birth, 
and usually disappears spontaneously. Premature or 
weak children are especially liable to the true variety, 
but in the majority of cases the jaundiced hue is due to 



LACTATION. 143 

great hyperemia of the skin followed by desquamation; 
in such cases there is no discoloration of the sclerotic. 



CHAPTER IV. 
LACTATION. 

After the mother has rested a few hours the child 
may be put to the breast ; such application favors uterine 
contraction, and at the same time the temporary secre- 
tion known as colostrum by its purgative properties 
induces a discharge of the meconium with which the 
bowels are loaded. 

Previous to the third day, or before full establishment 
of the lacteal secretion, the child should take the breast 
only once or twice daily ; afterward it must be applied 
regularly every two or three hours. At night the inter- 
vals between nursing should be gradually lengthened. 

The child usually requires no nourishment before it 
can be supplied by the mother ; if any is given mean- 
while it should be simply sweetened water. 

When the mother's health permits, and unless there 
is some contra-indication, such as a marked strumous 
diathesis, syphilis, phthisis, great debility, or excessively 
sore nipples, the child- should be nursed by her at least 
for a few months, as it favors the proper involution of 
the uterus and gives the child a better chance of living. 

If the mother cannot or will not nurse the child, a 
wet nurse should, if possible, be procured. She should 
be strong and healthy, between the ages of twenty and 
thirty-five years, and free from all traces of constitutional 
disease ; the breasts should be in a healthy condition, 
the nipples well formed r.nd free from cracks or erosions; 



144 OBSTETRIC SYNOPSIS. 

the milk should flow easily, and should, if possible, be 
carefully examined; the nurse's child should be near the 
same age as the child to be suckled, plump, well nour- 
ished, and free from all blemishes. The diet of the nurse 
should be plain, nutritious, and abundant. 

If the mother is unable to nurse the child, and a wet 
nurse cannot be procured, artificial or hand-feeding will 
be necessary ; the mortality of such children is much 
greater on account of the unsuitable food that is so 
often used. 

The substitute most suitable to all cases is cow's 
milk; it differs from human milk in containing less 
water and sugar and more casein, and must, therefore, 
be diluted with water and sweetened before use. Dilu- 
tion is necessary only during the first two or three months 
(about one part water to two parts milk) ; afterward pure 
milk warmed and sweetened may be given. In order to 
prevent the coagulation of the casein, lime-water should 
be added to the milk. In hot weather it is safer to have 
the milk boiled and then prepared in the usual way. 

When it is impossible to get good cow's milk, or 
when the latter disagrees with the child, condensed milk 
should be tried. The food must be prepared fresh for 
every meal, and given in moderate quantity at regular 
intervals ; the bottle must be scalded after each use, and 
the nipple, which should be used in preference to a tube, 
must be kept perfectly clean. 

During the first three months purely starchy food, 
such as corn flour, arrowroot, etc., must be avoided, as 
the child cannot digest it. For the majority of children 
before the sixth month milk should be the only food, 
but after that time the child may have occasionally 



PATHOLOGY OF CHILDBED. 145 

chicken or beef broth with bread crumbs, oatmeal, and 
if necessary, one of the various infants' foods may be 
commenced. 



CHAPTER Y. 
PATHOLOGY OF CHILDBED. 

The diseases and accidents which are liable to occur 
in connection with the lying-in period are as follows : — 

Disorders of lactation; puerperal septicaemia ; pelvic 
cellulitis and pelvic peritonitis; puerperal thrombosis 
and embolism; phlegmasia alba dolens ; puerperal in- 
sanity. 

I. DISORDERS OF LACTATION —These are numer- 
ous and always demand careful attention as well as care- 
ful treatment. 

It is sometimes necessary on account of death of the 
child, inabilit\^ to nurse, or a desire to wean it, to use 
means for getting rid of the milk as soon as possible; in 
order to accomplish this the diet should be restricted, a 
daily saline laxative given, and the breasts covered with 
a layer of lint or cotton-wool soaked in a spirit lotion, 
over which oiled silk is placed. Among the remedies 
recommended for this purpose are camphor, atropia or 
belladonna, and iodide of potassium internally. 

Generally all local treatment, except that which is for 
the patient's comfort, is unnecessaiy, for the secretion 
stops when the milk is no longer required. 

(a) Excess of milk accompanied by constant drib- 
bling, known as galactorrhea, is of common occurrence 
during the first weeks after delivery ; it is especially 
liable to occur in women of delicate constitutions. 
13 



146 OBSTETRIC SYNOPSIS. 

Whenever the mother's health is being affected by the 
drain upon her system the child should no longer be 
allowed to nurse, especially as the milk sooner or later 
must disagree with it. 

The above-mentioned means for stopping the secre- 
tion may then be applied, and in addition the breasts 
should be compressed by strapping. 

(6) Deficiency of milk is usually the result of defective 
nutrition. The requirements for the abundant secretion 
of milk are as follows : A liberal and nutritious diet ; 
regular rest ; moderate exercise in the open air ; freedom 
from anxiety; and, in certain cases, less frequent appli- 
cations of the child to the breast, cow's milk being occa- 
sionally substituted. 

(c) Sore nipples may be caused by aphthous condi- 
tions of the child's mouth, bat are most likely to occur 
when the skin is thin and tender and lacking in seba- 
ceous secretion, or when the nipples are retracted and 
difficult for the child to seize, as is often the case in primi- 
parae. 

The two varieties of sore nipple are : — 

Abrasions, which may- become small ulcers ; cracks 
or fissures, which are generally found at or near the base 
of the nipple. 

In either condition the suffering ma} r be intense 
when the child suckles, and the inflammation may ex- 
tend to the mammary gland. 

Treatment. — It is recommended to prepare the nipples 
for nursing in the latter months of pregnancy by bathing 
them with spirituous or astringent lotions. When nurs- 
ing has commenced, and the child has been removed from 
the breast, the nipples should be washed and thoroughly 






PATHOLOGY OF CHILDBED. 147 

dried. Cocoa-butter or mutton suet may be applied, 
and a shield worn as long as the mother is in the re- 
cumbent position. When the nipple becomes sore and 
painful one or more of the following- remedies may be 
employed : glycerite of tannin ; weak solutions of nitrate 
of silver; the mitigated stick; flexible collodion; com- 
pound tincture of benzoin ; nitrate of lead (gr. x) in gly- 
cerine (f§j); tincture of catechu; a mixture of sulphur- 
ous acid (f§ss), glycerite of tannin (fgss), water (f^j). 
Before putting the child to the breast the lotion should be 
washed off. If the child can be induced to suck through 
a nipple shield much relief will be temporarily afforded. 

(d) Inflammation of the breasts may result from en- 
gorgement of the lacteal tubes, exposure to cold, injury, 
mental emotions, or, as is frequently the case, from a sore 
nipple by spread of the inflammation. It may involve 
only one or two lobules and be comparatively superfi- 
cial, or may affect the entire breast. The breast is hard, 
tender, and enlarged ; there may be swelling of the axil- 
lary glands, and fever is alwa}'s present. 

The inflammation may terminate in resolution or in 
suppuration with the formation of one or more abscesses 
which may lead to the formation of fistulse. 

Suppuration is generally ushered in with rigors ; the 
skin over a particular portion of the breast becomes red 
and tense, and the abscess eventually bursts. The ab- 
scess usually points near the nipple; but when suppura- 
tion is deep seated the pus may burrow extensively 
beneath the glandular structure of the breast. 

Treatment. — Prophylaxis includes the treatment of 
sore nipples and guarding the breast from injuries of 
various kinds; engorgement of the lacteal tubes should 



148 OBSTETRIC SYNOPSIS. 

be prevented hy regular nursing, removal of the exces- 
sive secretion, gentle hand friction, and the application 
of heat. 

When the inflammation has commenced resolution 
should be favored by absolute rest (removal of the child), 
salines, aconite, and quinine. Pain may be relieved by 
giving opiates and applying hot fomentations, light 
poultices, belladonna, or a solution of atropia, the breast 
being supported by a bandage. 

The local application of ice has been highly recom- 
mended. When suppuration has taken place the abscess 
should be opened as soon as possible and the pus evacu- 
ated, the incision being made in a line radiating from 
the nipple to avoid severing the milk-ducts. The open- 
ing thus made should be dressed antiseptically to avoid 
long-continued suppuration. 

When sinuses and fistulas result the breast should be 
strapped and stimulating lotions or injections used, the 
secretion of milk being checked as soon as possible; 
sometimes it will be necessary to lay the sinuses open. 

2. PUERPERAL SEPTIC/EMIA, called " puerperal 
fever," is an acute contagious disease attacking women 
in childbed but identical with ordinary septicaemia. 
There are numerous theories regarding the nature and 
origin of the disease, among them are the following : — 

That it is a local inflammation producing secondary 
constitutional effects ; 

That it is an essentially zymotic fever, peculiar to 
and attacking only puerperal women ; 

That it is produced by the absorption of septic matter 
into the system, and is, therefore, identical with surgical 
septicaemia. 



PATHOLOGY OF CHILDBED. 149 

The latter theory is the one generally accepted at the 
present time. 

The cause of puerperal fever is septic poison in the 
system ; this poison may be produced within the body 
of the patient (autogenetic), or it may be conveyed to 
the patient from without (heterogenetic). 

The sources of self-infection (autogenetic) are de- 
composition of the tissues of the mother or of matter 
retained in the uterus or vagina that ought to have been 
expelled, such as coagula and small portions of mem- 
brane or placenta which have putrefied from the access 
of air. Some authorities claim that the conditions 
named are not the sources of infection, but that they 
furnish a favorable soil for the development of the 
poison. 

The sources of heterogenetic infection are probably 
any decomposing organic matter, some forms being more 
virulent than others. 

The poison may be carried from one patient to 
another, from the post-mortem or dissecting-room, or 
may be produced by the poison of erysipelas, scarlatina, 
and other zymotic diseases. It may be conveyed by the 
hands of the accoucheur, by the nurse, by sponges, etc., 
or by the atmosphere. 

The absorption of septic matter may occur at the 
placental site or in wounds of the cervix, vagina, and 
perineum ; in some cases the absorption is believed to 
have taken place through the intact vaginal or cervical 
mucous membrane. 

The pathology of the disease includes lesions which 
may be slight or may involve a large portion of the 
body ; these are as follows : — 



150 OBSTETRIC SYNOPSIS. 

Inflammation of the vaginal and uterine mucous 
membranes, small wounds of these parts being generally 
covered with diphtheritic patches ; 

Inflammation of the uterine parenchyma, and of the 
connective tissue adjacent to it; 

Inflammation of the ovaries; 

Inflammation of the peritoneum, which may involve 
only that found within the pelvis, or be general; 

Inflammation of the other serous membranes (pleura, 
pericardium, meninges, joints); 

Inflammation of the lymphatic glands ; 

Pyaemia with the formation of abscesses in various 
parts of the body. 

The symjrtoms vary greatly in different cases. The 
disease generally commences within the first five days 
after delivery, the onset being most common on the 
third. A sudden rise of temperature (102° or more) 
accompanied by rigors and quickening of the pulse are 
often the first symptoms which attract notice ; in some 
cases the temperature may quickly rise to 103° or 104°, 
and the pulse to 140. There is tenderness over the 
uterus, but little or no pain; the spleen is enlarged and 
tender; intelligence is unimpaired unless the tempera- 
ture has remained high when there may be delirium. 

The headache is severe; the tongue is coated, and 
becomes eventually dry and brown ; the teeth are covered 
with sordes ; the breathing is hurried, and the breath has 
a heavy sweetish odor. The abdomen is distended and 
tympanitic; vomiting and diarrhoea are of frequent 
occurrence, the latter being sometimes profuse and 
uncontrollable. The lochia are generally suppressed 
or altered in character, and the odor may be highly 
offensive ; the secretion of milk is often arrested. 



PATHOLOGY OF CHILDBED. 151 

The complications — such as peritonitis, pleurisy, 
pneumonia, pericarditis, and nephritis — are accompanied 
by their own symptoms, and variously modify the course 
of the disease. 

Death is the result of the complications, or the patient 
may pass into a typhoid condition with rapid or inter- 
mittent pulse, marked delirium, great tympanitis, and 
die of exhaustion within a week. 

Treatment. — Prophylaxis is the most important part 
of the treatment; it includes precautions taken by the 
patient, accoucheur, and nurse before, during, and after 
labor. 

The physician should not take charge of a case of 
labor whilst he is in attendance on a case of puerperal 
fever, infectious disease, or is engaged in the dissecting- 
room ; if there be a necessity for his attendance he must 
first take a full bath, make a complete change of cloth- 
ing, and, before examining the patient, should w T ash his 
hands and arms in an antiseptic solution. In order to 
guard against the sources of self-infection all clots, 
shreds of membrane, and pieces of placenta should be 
removed, and the uterus firmly contracted. 

The nurse must be scrupulously clean, and in wash- 
ing and syringing the patient should use antiseptic 
solutions. 

When the disease exists further absorption of septic 
matter should be prevented by vaginal, and, in some 
cases, by intra-uterine injections of antiseptic solutions. 

Intra-uterine injections should be used with caution, 
a fountain syringe being emplo} T ed for the purpose on 
account of its greater safety. 

The usual result of the repeated injections is a marked 



152 OBSTETRIC SYNOPSIS. 

lowering of the temperature ; if, however, the fever still 
continue and there be any foreign substance within the 
uterus, the fingers, forceps, or dull curette must be used 
to remove it. 

The temperature may be reduced by the cold bath, 
the wet sheet, applications of ice to the abdomen, or fre- 
quent sponging of the skin with cool water'; when there 
is much abdominal tenderness or tympanitis, flannel 
cloths wrung out of hot water and sprinkled with tur- 
pentine should be substituted for the cold applications. 

The medicines that may be employed for this pur- 
pose are: Quinine, salicylic acid, salicylate of sodium, 
antipyrin, alcohol, and, if the pulse is not weak, aconite. 
Opium is frequently indicated to relieve pain or restless- 
ness, or to assist in checking the diarrhoea. 

Nourishment must be given frequently in the form of 
easily digestible food to which stimulants may be added 
as indicated. 

The complications which so often arise must be 
treated on general principles. 

3. PELVIC CELLULITIS AND PELVIC PERI- 
TONITIS. — Pelvic cellulitis is an inflammation affect- 
ing chiefly the connective tissue surrounding the gene- 
rative organs contained within the pelvis; pelvic peri- 
tonitis is an inflammation attacking that portion of the 
peritoneum which covers the pelvic viscera. These dis- 
eases which are frequently associated are not limited to 
the puerperal state, and when they do occur in connec- 
tion with it, may or may not be accompanied by general 
septicaemia. 

They are produced by extension of inflammation 
from the uterus, ovaries, or Fallopian tubes; by irritat- 



PATHOLOGY OF CHILDBED. 153 

ing discharges from the tubes or ovaries ; or by mechani- 
cal injury. 

Cellulitis rarely exists without peritonitis. 

The symptoms of these diseases may show themselves 
within a few days after delivery or may come on after a 
period of several weeks. Those which first attract atten- 
tion are a rigor or chilliness, and the accompanying pain 
in the lower part of the abdomen. The pain may be 
slight or may be excessive with occasional intermissions. 
The tenderness on pressure is marked when there is peri- 
tonitis, less so when there is uncomplicated cellulitis. 

The temperature is often very high (104°), but gene- 
rally there are marked remissions. 

The pulse varies from 100 to 120. Nausea and 
vomiting accompany the peritoneal inflammation. 

The vagina is found hot, swollen, and tender, and a 
thickness or induration may be detected near the uterus; 
if there has been much exudation the uterus is displaced 
and more or less fixed. 

The inflammation may end in resolution or suppura- 
tion ; in the former case the acute symptoms subside, 
the tenderness disappears, the swelling decreases and 
may be absorbed, or permanent adhesions with fixation 
and displacement of the uterus may result ; if suppura- 
tion occur the acute symptoms continue and are accom- 
panied by the characteristic rigors and exacerbations of 
temperature until the abscess has formed and opened 
either through the abdominal wall or into the rectum, 
bladder, vagina, or, as sometimes happens^ into the peri- 
toneal cavity when general peritonitis results. 

Suppuration is more likely to occur in cellulitis than 
in peritonitis, and is said to be rare in either case except 
when associated with puerperal fever. 



154 OBSTETRIC SYNOPSIS. 

The prognosis for recovery is good, but the liabilit} r 
to general peritonitis, exhausting suppuration, and per- 
manent alteration of structure of the parts makes it less 
favorable. 

Treatment. — The most important points are : Relief 
of pain ; absolute rest. 

For the relief of pain opiates should be given repeat- 
edly in large doses, and warmth and moisture applied in 
the form of poultices to the lower part of the abdomen. 

Local abstraction of blood by leeching is recom- 
mended in the earty stage of the disease. 

For the pyrexia quinine is useful and may be given 
with the opiates. The constipation thus produced can 
be overcome by enemata or small doses of castor-oil. 

Small doses of tartar emetic and calomel may be 
combined with morphia and given during the acute 
stage ; when this stage is passed the daily local appli- 
cation of tincture of iodine or some other form of coun- 
ter-irritation should be employed. 

When the abscess has formed the aspirator should be 
used, or if it is superficial a free incision may be made 
and antiseptic treatment instituted. 

During all of this time absolute rest in bed is neces- 
sary ; the diet should be abundant, simple, and nutri- 
trious ; stimulants may be necessary ; tonics are indi- 
cated and generally beneficial. 

4. PUERPERAL THROMBOSIS AND EMBOLISM. 

Thrombosis is a partial or complete blocking of a 
bloodvessel by coagulation of the blood. 

Embolism is an obstruction due to the impaction of 
a separated portion of a thrombus formed elsewhere. 

These obstructions are liable to occur in arteries or 



PATHOLOGY OF CHILDBED. 155 

veins, but it is the pulmonary artery that is most com- 
monly affected during the puerperal state. 

The causes of coagulation are: Excess of fibrin in 
the blood; a stagnant or arrested circulation; mechani- 
cal obstruction. 

Embolism, as has been said, is produced by the car- 
rying of all or a portion of the clot to the right side of 
the heart, whence it is sent to the pulmonary artery. 

Obstruction of the general arterial system may be 
due to alteration of the blood or to cbtachment of vege- 
tations on the cardiac valves. 

The symptoms of thrombosis and embolism are almost 
identical, and usually come on suddenly. Intense dysp- 
noea, giving rise to violent efforts to get more air, sets in 
and continues until the patient dies of asphyxia. The 
face is pale or cyanosed ; the pulse is feeble and at length 
imperceptible ; a systolic murmur may be heard over the 
pulmonary artery ; the intelligence is unimpaired almost 
to the last. 

Death generally results from asphyxia or s} r ncope, 
but if the obstruction be only partial, if sufficient blood 
may pass to keep the patient alive, and a sudden supply 
of oxygenated blood be not demanded by any undue 
exertion, the patient may live until the obstruction is 
removed. 

Obstruction of the general arterial system causes 
symptoms which vary with the arteries affected and the 
amount of the obstruction. 

Treatment. — The indications for treatment are : Ab- 
solute rest in bed, no movement whatever being allowed; 
administration of stimulants. If the patient survive the 
onset of the attack ammonia and other alkalies have been 



156 OBSTETRIC SYNOPSIS. 

recommended to prevent further coagulation and to favor 
absorption of the clot alread\- formed. 

5. PHLEGMASIA ALBA DOLENS.— A swelling of 
one or both legs occurring after labor, but rarely before 
the second week. The causes of the swelling are : — 

Thrombosis of the uterine veins, which may extend 
to the iliac and femoral veins, or thrombosis of the 
femoral vein alone ; 

Phlebitis resulting in thrombosis. 

Phlegmasia dolens is a frequent complication of sep- 
ticaemia, and on this account has been thought to be 
always produced by that disease or to be dependent on it. 

The symptoms are : Acute pain extending the length 
of the limb and along the vein ; swelling of the limb, 
commencing within the first twenty-four hours after the 
onset of the pain ; restlessness ; elevation of tempera- 
ture; rapidity of the pulse. 

The swelling usually begins in the groin and extends 
downward ; it may be limited to the thigh or may in- 
volve the entire limb. The part of the limb affected is 
hard, tense, of a shiny white color, and unyielding on 
pressure except at the onset or toward the termination 
of the affection. 

The left leg is most frequently attacked, but the 
swelling may extend to the other limb. 

After the swelling has set in the pain is not so severe, 
but it does not cease altogether for a week or two when 
the acute symptoms usually subside. The swelling 
gradually diminishes, but absorption may not be com- 
pleted for several months. Too early use of the limb 
ma} T cause a recurrence of the swelling ; in rare cases 
suppuration takes place. 



PATHOLOGY OF CHILDBED. 157 

The greatest danger is, detachment of a portion of 
the thrombus and possibly fatal pulmonary obstruction. 

Treatment. — The limb should be kept at perfect rest 
in the horizontal position in order to guard against pul- 
monary embolism ; pain may be relieved by the constant 
application of heat and moisture in the form of poultices 
or turpentine stupes, also, by the frequent use of 
anodynes, liniments, and opiates given internally; the 
diet must be light, but nutritious and abundant ; stimu- 
lants may be required. 

The remedies for internal use are : Nitrate of potash; 
chlorate of potash; carbonate of ammonia; iron; qui- 
nine ; and tonics. 

After the acute symptoms and all pain have subsided 
the limb should be firmly and evenly bandaged from be- 
low upward; but until the swelling has commenced to 
disappear it should remain elevated and at rest. 

6. PUERPERAL INSANITY.— Insanity may come 
on during pregnancy, during labor, or during the puer- 
peral state and the period of lactation. 

Insanity coming on after labor is the most common 
variety. There are two forms of the disorder : acute 
mania, which usually comes on within the first week or 
two after delivery; melancholia, which usually com- 
mences later, but during some part of the period of 
lactation. 

The causes are : Heredity; moral influences; physical 
influences. Exhaustion produced by hemorrhage, albu- 
minuria, septic matter in the blood or prolonged lacta- 
tion predispose to it. 

The prognosis should be guarded ; it is said, however, 
that most of the patients recover. In delirium of the 
14 



158 OBSTETRIC SYNOPSIS. 

first few days after delivery death may occur or the dis- 
ease may terminate in permanent mental derangement. 

Most of the cases of insanity of lactation recover 
after the child has been weaned. 

Treatment. — Acute mania requires abundant nour- 
ishment and sleep. 

Solid food should be given if possible, but if she 
refuse to take it, liquids must be forcibly introduced ; 
the bowels should be regulated by occasional aperients ; 
stimulants should be withheld until exhaustion necessi- 
tates their use. 

Sleep must be induced by the use of chloral by the 
mouth or rectum, bromides, warm baths, or the wet pack. 

The room should be kept cool, darkened, and quiet. 

Cases of chronic melancholia are best treated in an 
asylum. 



PART VI. 

OBSTETRIC OPERATIONS. 



CHAPTER I. 
INDUCTION OF ABORTION AND PREMATURE LABOR. 

The induction of abortion is an operation not de- 
signed to save the child, but performed in the interest 
of the mother; the induction of premature labor is a 
conservative operation performed in the interests of 
both mother and child. 

Abortion may be brought on at any time before the 
period of viability (seventh month). 

The induction of premature labor should not be 
undertaken until after that period. 

Before undertaking either of the operations a con- 
sultation must invariably be held. 

I. ARTIFICIAL ABORTION.— The induction of 
abortion is justifiable when one or more of the follow- 
ing conditions exist: — 

Such obstruction of the birth canal that the delivery 
of a living child cannot be effected ; disease of the 
mother, induced or aggravated to such an extent by the 
pregnant condition that her life is endangered; retrover- 
sion, retroflexion, or procidentia, which cannot be re- 
placed ; disease or death of the embryo or foetus. 

The mode of operating varies according to the time 

"(159.) 



160 OBSTETRIC SYNOPSIS. 

of the operation. During the early months a sound or 
metallic bougie may be passed within the uterus so that 
the internal os is slightly dilated and partial detachment 
of the membranes effected, rupture of the ovum being 
avoided if possible. If this fails after several daily 
repetitions, the cervix may be dilated with a tent which 
generally gives rise to uterine action. These means 
failing, the finger may be passed through the dilated 
cervix and the attachments broken up, or the ovum may 
be punctured with a sound. 

Every effort should be made to bring the ovum awaj' 
intact, and on this account the earlier the abortion is 
induced the more favorable the termination is likely to 
be. In the latter months it is generally better to punc- 
ture the membranes at once, as the ovum is not likely to 
be expelled intact ; for this purpose a narrow pointed 
uterine sound may be used. Various drugs, electricity, 
and intra-uterine injections have been employed, but are 
more dangerous and less effective than the other means. 

2. PREMATURE LABOR.— The induction of pre- 
mature labor is justifiable when one or more of the fol- 
lowing conditions exist : — 

Pelvic contraction or tumors; diseases endangering 
the mother's life, such as uterine hemorrhage, eclampsia, 
obstinate vomiting, etc. ; habitual death of the foetus before 
full term ; or large size of the foetal head, which may be in- 
dicated by the histories of previous pregnancies. 

The methods of operating are numerous and generally 
effective. The following are the means that may be em- 
ployed : — 

Vaginal douches of hot or cold water, and vaginal 
tampons ; 



USE OF THE FORCEPS. KU 

Artificial dilatation of the os with hydrostatic di- 
lators ; 

Introduction of a flexible bougie into the uterus 
between the membranes and the uterine wall, the bougie 
remaining in situ until labor comes on ; 

Puncture of the membranes, when the operation is 
not performed in the interest of the child ; 

Intra-uterine injections of tar-water or warm water, 
and the introduction of carbonic acid gas into the va- 
gina — each of these methods having been abandoned as 
unsafe ; 

Stimulation of the uterus by friction or electricity ; 

Ergot and numerous other drugs, none of which 
ought to be used. 

In ordinary cases the best method is the introduc- 
tion of a flexible bougie into the uterus ; in connection 
with this the vaginal douches may be employed, but, if 
there is a necessity for haste in the later stage, dilatation 
may be more rapidly effected by the use of the hydros- 
tatic dilator of Barnes. The most rapid method from 
the first is puncture of the membranes and insertion of 
a tent, the effect of the latter being continued until the 
hydrostatic dilator can be used. 



CHAPTER II. 
USE OF THE FORCEPS. 

The obstetric forceps consists of two separate blades 
curved to fit the child's head and, in most of the modern 
instruments, to correspond with the axis of the pelvis. 

There are two varieties of forceps — the short and the 
14* 



1G2 



OBSTETRIC SYNOPSIS. 




Fig. 35. — Parvin-Davis forceps. 

long — but of each of these 
varieties there are numerous 
modifications. 

Straight forceps, curved 
only to fit the child's head, 
and without the pelvic curve, 
were made short and long ; the 
former could be used only 
when the head was near the 
perineum, while the latter 
would not allow the head to 



Fig. 34.— Wallace forceps. 



USE OF THE FORCEPS. 163 

be grasped in the axis of the brim, nor could traction be 
made in the direction of that axis. 

Since the invention and addition of the pelvic curve 
the straight instrument has been almost entirely unused, 
except for rotation of the head which is sometimes neces- 
sary in occipito-posterior positions. (See page 109.) 




Fig. 36. — Tarnier's forceps. 

Simpson's " axis-traction " forceps and Tarnier's for- 
ceps have supplementary handles attached to the blades 
near the lower margins of the fenestras; traction being 
made by this handle and not by the others less force is 
required, the blades are not likely to slip, rotation of the 
head is not interfered with, and the direction of the trac- 
tion is in the axis of the pelvis. 

Good forceps should be smooth, stiff, and strong with 
moderately long handles ; the cranial curve should be of 
medium sharpness, and the pelvic curve not more than 
30 or 35° ; the tips of the blades should be one-half to 
one inch apart when the handles are closed ; the outside 
measurement across the blades at the widest part should 
not be greater than three and three-eighth inches. 



164 OBSTETRIC SYNOPSIS. 

The action of the forceps is threefold : as a tractor ; 
as a lever ; as a compressor. The chief action, however, 
is as a tractor. It acts as a lever when a firm hold is 
had on the head and when slight oscillatory movements 
are made, as is necessary in some cases of impaction of 
the head. It acts as a compressor, but this action is 
generally not considered desirable. 

In addition a dynamic action has been claimed for 
the instrument ; it occasionally happens that the intro- 
duction of the blades excites increased uterine action 
through the reflex irritation induced by the presence of 
a foreign bod} r in the vagina. This action can never be 
relied on. 

The application of the blades and the use of the in- 
strument is an easy and safe operation when the head is 
low in the pelvis; when the head is situated at or above 
the brim of the pelvis the operation is more difficult, and 
at the same time more dangerous. 

The indications for the use of the forceps are : — 

Cases where the ordinary forces of labor are insuffi- 
« 
cient to overcome the obstacles to delivery, as in nar- 
rowing or partial obstruction of the birth canal, uterine 
inertia, large foetal head, malpositions, etc.; 

Cases where speedy deliveiy is demanded in the inte- 
rest of either mother or child, as in eclampsia, exhaus- 
tion, prolapse of the cord, hemorrhage, etc.; 

Cases where the head is engaged in the pelvis, and 
there has been no advance for some time, the u rebound" 
during the intervals of the diminishing pains having 
ceased. 

The conditions necessary for the use of the forceps 
are : — ■ 



USB OF THE FORCEPS. 1(>5 

Rupture of the membranes ; 

Complete dilatation of the os and retraction of the 
cervix ; 

Knowledge of the position of the presenting part; 

Emptiness of the bladder and bowels. 

The rule was that the blades should be applied to the 
head only, whether it come first or last, and whether the 
position be vertex or face ; they have been, however, in 
some cases successfully applied to the pelvis when that 
part presented. 

In rare cases the blades may be passed within the 
uterus before there has been complete dilatation and 
retraction of the cervix for the purpose of bringing the 
head into the pelvis, but the danger of cervical laceration 
is very great. 

The use of anaesthetics in application of the forceps 
is generally unnecessar}^ except in the high operation. 

The patient should lie on her left side and be brought 
to the edge of the bed with the nates parallel to it, the 
body lying across the bed and nearly at right angles to 
the hips. 

In a difficult case she may be placed on her back in 
the lithotomy position at the edge of the bed ; in this 
position, however, there is not only more exposure but 
greater risks to the perineum. 

The blades should, as a rule, be applied to the sides 
of the pelvis and not invariably to the sides of the head 
as was formerly taught. 

The operation includes three acts : Introduction of 
the blades; locking; extraction. 

Introduction. — This part of the operation must be 
done during the intervals between the pains. The 



166 OBSTETRIC SYNOPSIS. 

blades having been thoroughly cleansed, warmed, and 
lubricated, on account of the arrangement of the lock, 
the lower one — when the patient lies on her left side — 
should be introduced first. 

This blade (which always passes to the left side of 
the mother's pelvis) is taken in the left hand and gently 
passed in the axis of the pelvis along the palmar surface 
of the right, which has been previously introduced into 
the vagina, until its point rests just under the tips of the 
fingers b} r which the blade is guided into position on the 
head. At first the handle should be raised and directed 
somewhat forward, but as the blade passes up the handle 
must be carried backward. 

In pushing the blade into position on the head no 
force should be used, and the fingers of the right hand, 
still within the vagina, should protect the cervix from 
injury as the blade is being guided into its position. 

If any obstruction be felt the blade must be partially 
withdrawn, and gentle efforts continued until it passes 
readily. 

When fully inserted the handle is drawn back toward 
the perineum and held there by an assistant until the 
second blade has been taken by the right hand and intro- 
duced into the right side of the pelvis; being guided by 
the palmar surfaces of the fingers of the left hand the 
blade passes to the other side of the child's head. 

In some cases, especially second positions of the 
vertex, the second or right blade of the instrument 
commonly used cannot be introduced after the first 
or left blade is in position; in order to overcome this 
difficulty by permitting either blade to be applied 
before the other, which is not possible in other instru- 



USE OF THE FORCEPS. 



167 



ments on account of the crossing of the handles and 

arrangement of the lock, an instrument with parallel 

handles has been devised by Prof. William S. Stewart, 
of Philadelphia. 




Fig. 37.— William S. Stewart's forceps. 

In addition to this advantage the instrument has the 
following merits which have been proved by experience 
in the use of it : — 

Impossibility of their slipping if the blades have 
been properly applied ; 

Moderate and even compression, the degree of com- 
pression being regulated by the amount of resistance ; 

Greater facility for making traction. 



168 OBSTETRIC SYNOPSIS. 

Locking. — When the introduction has been effected 
the right handle of the instrument rests upon the left 
one, and if the blades have been properly applied there 
is usually no difficulty in locking them. If, however, 
this cannot be done b}^ gentle movements, one or both 
blades must be partially or entirely withdrawn and again 
introduced. 

Care is to be taken in locking that hairs or folds of 
skin are not caught in the lock. 

Traction. — When the locking has been effected, and 
before traction is made, the finger should be introduced 
to make sure that the blades have been properly applied 
to the head, and that there is no danger of their slipping. 

Traction must be made in the direction of that part 
of the pelvic axis in which the head lies; when the head 
is high, downward and backward; when it has reached 
the lower part of the pelvis, downward and forward until 
finally, as the head emerges, the handles are carried up 
tow T ard the abdomen. 

Traction should be made only during the pains ; if 
the pains have ceased, or occur at long intervals, the 
uterus should be stimulated By external friction, traction 
being meanwhile made regularly at intervals of a few 
minutes. 

It should be steady — oscillatory movements being 
justifiable only in rare cases where the head does not 
advance. Rotation of the head generally occurs inde- 
pendently of the forceps if their hold is occasionally 
relaxed. 

Removal of the forceps when the head has been 
brought to the perineum, and before it passes through 
the vulvar orifice, is recommended by some authorities; 



USE OF THE FORCEPS. 169 

others retain the hold with the instrument until the head 
is delivered that its exit may be retarded until the vulvar 
orifice is sufficiently dilated. 

Vectis. — The vectis consists of a handle and single 
blade having a cranial but no pelvic curve. Its action 
is that of a tractor and lever, but since the introduction 
of the forceps its use has been almost abandoned. 




Fig. 38.— The vectis. 

It may be used, however, with advantage in correct- 
ing malpositions of the head, especially cases of occipito- 
posterior presentations. When the head is in the lower 
part of the pelvis, and the pains have not entirety ceased, 
it can be used as a substitute for the short forceps ; but 
in all cases, on account of the frequent applications to 
the different parts of the head and the manner in which 
the instrument must be used, there is great risk of injur- 
ing the maternal tissues. 

Fillet. — The fillet, one of the oldest of obstetric in- 
struments, consists, as it is now made, of a slip of whale- 
bone fixed into a handle composed of two separate halves 
which join into one. 

By slipping it over the occiput or face and making 
traction malpositions may be corrected or the head may 
be brought down. It can be used as a substitute for 
the vectis, but in most cases the forceps should have the 
preference. 
15 



HO 



OBSTETRIC SYNOPSIS. 




Fig. 39.— The fillet. 



CHAPTER III. 
VERSION. 

A turning of the foetus by which the presentation is 
changed. The success of the operation depends on the 
mobility of the foetus in utero. The risks and difficulties 
of the operation are less if the amniotic liquor is present 
or has only recently escaped. 

If the uterus is tightly contracted on the foetus, at- 
tempts at version may be followed by rupture of the 
organ. 



VERSION. 171 

Before undertaking the operation the bladder and 
rectum must be emptied. 

The indications for the operation are conditions im- 
periling the life of either mother or child, — such as trans- 
verse presentations, hemorrhage, certain cases of con- 
tracted pelvis and of prolapse of the cord. 

The methods of performing version are three, viz : — 

External method, effected by external manipulation 
only ; 

Internal method, effected by the hand introduced 
within the uterus, the external hand being used only to 
steady the uterus ; 

Combined or bi-polar method, in which one hand is 
used in the vagina, while the other assists in moving the 
foetus by pressure through the abdomen. 

The varieties of version are two: Cephalic; podalic. 

I. CEPHALIC VERSION.— This variety of turning, 
although the first to be introduced, was not used with 
much advantage before the invention and use of the ob- 
stetric forceps ; since their introduction cephalic version 
has been more or less restricted on account of the many 
favorable conditions necessary to its performance. It 
may be performed by the external method, with both 
hands upon the abdomen, or by the combined or bi-polar 
method. 

(a) External method. The operation must be per- 
formed while the foetus is very movable, therefore before 
or shortly after rupture of the membranes. It is indi- 
cated in the latter part of pregnancy or at the commence- 
ment of labor to correct malpresentations, especially 
transverse or oblique positions of the foetus. 

The positions of the head and breech having been 



172 OBSTETRIC SYNOPSIS. 

discovered by use of the usual methods of diagnosis, and 
a change of presentation found to be indicated, the opera- 
tion may be commenced. 

The patient should lie on her back; the operator 
standing at her right side grasps the foetal head with his 
right hand, while the left is applied to the other end of 
the body. The head and breech are then pushed in 
opposite directions until the head is above the brim of 
the pelvis where it must be held, until engaged, by the 
patient lying on her side, by the hand, or, by means of 
pads placed on the abdomen at the breech and head and 
held in position by a bandage ; if labor has commenced 
the membranes should be ruptured so that the head may 
be retained in its position by the uterine contractions; the 
forceps may be applied as soon as their use is indicated. 

(b) Combined method (bi-polar). In the majority of 
cases labor has been a considerable time in progress 
before the operation of turning is undertaken ; in these 
cases the combined method — with one hand internal and 
the other external — must be employed. 

The presentation being that of the shoulder, the right 
or left hand is passed into the vagina and the other 
placed upon the abdomen ; the shoulder is then pushed 
gradually in the direction of the feet, while the external 
hand presses the head toward the brim where it may be 
held until the other hand is withdrawn from the vagina 
and presses the breech upward. 

Cephalic version is not performed by the internal 
method alone on account of the difficulty of seizing the 
head and retaining it in position. 

2. PODAUC VERSION.— This variety of turning is 
the one most frequently employed, being indicated when 



VERSION. 173 

cephalic version is contra-indicated or cannot be readily 
performed, and in certain cases of placenta praevia, flat- 
tened pelvis, prolapse of the cord, or where rapid de- 
livery is necessary. 

It can be performed by the combined method or by 
the internal method alone. 

(a) Combined method (bi-polar). The operation may 
be performed by this method at an early stage of labor, 
and when the os is only enough dilated to admit the 
fingers, provided the amniotic liquor has not drained 
away so completely that the uterine wall is closely con- 
tracted about the foetus. The patient may lie on her 
back or left side, and either hand may be introduced 
into the vagina. 

The presentation being that of the head, the fingers 
are passed within the cervix and the head pushed up- 
ward in the direction of the occiput, while the external 
hand pushes the breech downward in the direction of the 
abdomen of the foetus. 

When the shoulder arrives at the os it should be 
pushed in the same direction as the head ; as soon as a 
knee or foot is felt it must be grasped by the fingers and 
the membranes immediately ruptured, if they have not 
been ruptured already. 

Traction should then be made on the leg until the 
greater part of the thigh has passed through the os. It 
generally makes no difference which leg is seized, but in 
cases of flattened pelvis, where there is more room on 
one side than on the other, the occiput should be brought 
to the wider side by seizing the leg which corresponds to 
that side. 

When the presentation is that of the shoulder, ce- 
15* 



174 OBSTETRIC SYNOPSIS, 

phalic version is generally indicated ; but if the mem- 
branes are intact or have not been long ruptured, podalic 
version by the combined method may be attempted in 
the manner just described. 

(6) Internal method. This method is the one most 
frequently employed, and if attempted before escape of 
the amniotic liquor is not difficult. The patient may lie 
on her back or left side ; the dorsal aspect of the finger, 
hand, and forearm having been well oiled, the whole hand 
(right or left) in the form of a cone should be slowly 
passed into the vagina and gradually inserted within the 
uterus until the palm of the hand rests on the child's 
abdomen. 

If the membranes be now ruptured escape of the 
waters is prevented by the hand and arm which act as a 
plug; the hand may be pressed up until a knee or foot 
is reached, either of which should be gently drawn down- 
ward, assistance being meanwhile given by the external 
hand in pushing down the breech and in elevating the 
head. 

If the os is well dilated both limbs may be brought 
down ; if it is only partially dilated, and one of the limbs 
remains flexed on the body of the child, the other limb 
only should be brought down. 

In presentations of the shoulder it is preferable to 
seize the lower leg or that on the same side as the pre- 
senting shoulder (Galabin); many authorities, however, 
recommend the seizure of the opposite limb. 

When all of the amniotic liquor has escaped the 
uterus becomes tightly contracted on the foetus and the 
shoulder is impacted in the pelvis ; in such eases ver- 
sion is a most difficult and dangerous operation. 



EMBRYOTOMY. 175 

If the attempt at version fails, mutilation of the foetus 
will be necessary. 

The use of anaesthesia in version is regulated by the 
variety of the operation, the methods employed, and the 
difficulties encountered. 

Cephalic version may be performed without an anaes- 
thetic, especially if the membranes are unruptured. 

Podalic version may also be performed without an 
anaesthetic under the same circumstances ; but in either 
case if the uterine contractions are active, partial or 
complete anaesthesia will be found of great assistance. 

In all difficult cases complete anaesthesia is necessaiy. 

Attempts at version should be made only during the 
intervals between the pains; if a uterine contraction 
occur while the operation is being performed, the hand 
must remain motionless until the contraction has ceased. 



CHAPTER IV. 
EMBRYOTOMY. 

An operation involving destruction and mutilation 
of the child in order to facilitate or render possible its 
extraction. It is performed in the interest of the mother 
only, being justifiable in- cases where any other procedure 
is likely to prove fatal to her; some authorities condemn 
the operation as unjustifiable while the child is alive. 

The indications for embryotomy are : Want of pro- 
portion between the foetus and the birth canal, as great 
size of the head or of the entire foetus, narrowing or 
obstruction of the pelvis (conjugate diameter less than 
three inches and greater than one and a half inches); 



176 



OBSTETRIC SYNOPSIS. 



failure in the normal mechanism of labor, especially 
where there is impaction of the shoulder or face ; 

Death of the foetus (where artificial extraction is 
necessary). 

The varieties of the operation are : Craniotomy ; 
decapitation ; e maceration . 

I. CRANIOTOMY.— The stages of this operation are 
two: perforation, and extraction. 

(a) Perforation. Before commencing the operation 
the bladder and rectum should be emptied, and the 
patient placed on her back with the hips drawn over the 
edge of the bed ; if extraction is to be performed im- 
mediately after perforation the os must be well dilated 
before commencement of the operation. An anaesthetic 
is usually not necessary. 




Fig. 40. — Smellie's scissors. 



In order to keep the head in its position the hands of 
an assistant should make pressure through the abdominal 
wall"; the obstetric forceps are sometimes applied to the 
head for this purpose. 

Perforators are of various forms ; in most of them 
the pointed blades are separated and made to do their 
cutting by approximating the handles. Two fingers of 
the left hand having been introduced within the vagina, 
the perforator, held by the right hand, is gently passed 



EMBRYOTOMY. 177 

along their palmar surfaces and guided to the presenting 
part of the skull. 

The instrument is held perpendicular to the head 
and made to perforate it by firm pressure combined with 
a boring movement, the sutures and fontanelies being 
avoided if possible^ as they are likely to be closed when 
the bones are compressed. 

When the blades have penetrated as far as their 
shoulders the cut is made by approximating the handles; 
the instrument is now turned and a similar cut made at 
right angles to the first, after which it is thrust deep 




Fig. 41. — Simpson's perforator. 



into the brain-substance and moved about in order to 
thoroughly break up the latter ; the instrument is then 
carefully withdrawn. 

As the brain-substance escapes the cranial bones 
usually collapse. 

(b) Extraction. If there be no necessity for rapid 
delivery, the pains still being active, a short delay of a 
few moments between perforation and extraction will 
allow the skull to collapse and become moulded to the 
cavity of the pelvis. 

Extraction may be effected with the obstetric forceps, 
craniotomy forceps, cephalotribe, cranioclast, crotchet, 
the blunt hook, by version^ or by lamination. 



178 OBSTETRIC SYNOPSIS. 

The ordinary obstetric forceps, on account of the 
slight compression which can be exerted, is generally 
not serviceable ; when the operation has been performed 
with this instrument in position on the head extraction 
ma}' be attempted with it. 

Craniotomy forceps should be introduced with one 
blade through the perforation and the other outside the 
scalp ; traction may be made during the pains to bring 
the head down if possible ; but should the obstruction 
be great it will be necessary to break up and remove the 
cranial bones. The objection to this method of extrac- 
tion is the risk of injuring the maternal structures. 



Fig. 42. — Craniotomy forceps, 

The cephalotribe acts as a crusher and tractor. It 
consists of two strong blades which can be approximated 
by a screw attached to the handles. The blades which 
have a slight pelvic curve are applied in the same man- 
ner as those of the obstetric forceps; when they are in 
position the crushing can be done by slowly turning the 
screw; extraction may then be effected by making trac- 
tion in the axis of the pelvis, during the pains if possible. 

Care should be taken that spicule of bone do not 
project and cause injury. 

In some cases after one part of the head has been 
crushed it may be necessary to remove the instrument 
and apply it to some other part. 



EMBRYOTOMY. 179 

When there is not too great pelvic deformity omphal- 
otripsy is the safest and easiest method of extraction. 

The cranioclast is a powerful craniotomy forceps. 
One blade is passed between the cranial bones and the 
scalp, the other through the perforation in the skull; 
the bone is then grasped and twisted until it is detached 
and can be drawn out, this process of detachment and 
extraction being continued until the entire cranium has 
been removed. This method of extraction is not only 
tedious but dangerous. 

The crotchet, a sharp-pointed hook ; was formerly 
much used for extraction ; as it is liable to slip or break 
through the bone to which it is attached and cause 
injury to the maternal structures, its use has been almost 
abandoned. 

The blunt hook is a safer instrument and may be 
used to draw down the chin or thrust into an orbit; 
when the after-coming head has been perforated traction 
may be made with this instrument inserted at the base 
of the skull. 

Version with extraction of the feet first has been rec- 
ommended by some authorities and condemned by others. 

Lamination, or division of the head into two or more 
segments, has been performed by use of the forceps saw, 
but is of doubtful utility. 

2. DECAPITATION.— This operation is indicated in 
neglected shoulder presentations where turning cannot 
be effected. 

The methods by which it may be performed are : — 

Division of the neck with a blunt-pointed pair of scis- 
sors, the neck having been drawn down by pulling on an 
arm until the blunt hook can be applied ; 



180 OBSTETRIC SYNOPSIS. 

Division of the neck by means of a sharp hook, a 
piece of cord, or a wire ecraseur. 

After decapitation, delivery of the body is usually 
not difficult, delivery of the head being effected with the 
cephalotribe or blunt hook. 

3. EVISCERATION.— The opening and evacuation 
of the large cavities of the trunk. 

This operation should only be resorted to when the 
neck is inaccessible. The chest may be opened with 
the perforator or scissors ; after some of the contents 
have been removed the foetus may be doubled on itself 
and extracted by means of the crotchet or blunt hook. 



CHAPTER Y. 
ABDOMINAL SECTION. 

The operation for removal of the foetus through the 
abdominal wall has been performed according to various 
methods for many years; the results of the operations 
have been to a large extent unfavorable. 

It should be undertaken in the interest of the mother 
only; but if she has died the object will then be to ex- 
tract a living child. 

The indications for the operation are : Want of pro- 
portion between the foetus and the birth-canal, — as nar- 
rowing or obstruction of the pelvis, the conjugate di- 
ameter being less than one and a half inches, and the 
transverse diameter which bisects it less than three 
inches, — so that delivery cannot be effected by embryot- 
omy without greater risks to the mother ; 

Death of the mother during labor or during the latter 
months of pregnancy. 



ABDOMINAL SECTION. 181 

The operation should be undertaken at an early stage 
of labor before the patient has become exhausted, — the 
high mortality being due in great part to delay and 
fruitless efforts at extraction by other means. 

The varieties of the operation are : — 

Gdesarean section ( G astro- Hysterotomy) ; 

Porro's Operation (Gastro-Hysterectomy) ; 

Porro-Muller Operation; 

LaparchElytrotomy ( Gastro-Elytrotomy). 

I. C/ESAREAN OPERATION.— The variety of ab- 
dominal section first performed for the extraction of the 
foetus. Before commencing the operation the bladder 
and rectum should be empty, the os at least partially 
dilated, and the membranes ruptured in order to permit 
escape of the amniotic liquor. The patient must be 
anaesthetized and arranged for the operation as in ordi- 
nary cases of abdominal section. 

An incision six inches in length is made in the linea 
alba ; after all bleeding has ceased the peritoneum may 
be divided in the extent of the external incision when 
the uterus will be exposed. 

The uterus having been pulled forward by an 
assistant, an incision is quickly made through the mid- 
dle of the anterior wall; when the membranes have 
been reached a director is passed in and the incision 
carried upward almost as far as the external one, care 
being taken not to cut through the placenta if possi- 
ble. 

The edges of the uterine incision are now hooked up 
against the abdominal wall so as to prevent escape of 
blood and amniotic liquor into the peritoneal cavity. 

The child may be extracted by seizing the head or 
16 



182 OBSTETRIC SYNOPSIS. 

the feet ; the cord should be immediately tied and di- 
vided. 

The placenta may be detached and removed at once 
or allowed to remain for a few minutes until the blood 
in the sinuses has coagulated, good contraction of the 
uterus being meanwhile secured by grasping and com- 
pressing it with the hand. 

If the hemorrhage is not checked by this means the 
placenta should be immediately removed, and an appli- 
cation of Monsel's solution of iron made to the placental 
site. 

The uterine and peritoneal cavities having been 
cleansed, and the uterine and abdominal sutures applied, 
the dressings and subsequent treatment are carried out 
with the usual antiseptic precautions. 

2. PORRO'S OPERATION.— The removal of the 
uterus, tubes, and ovaries after Cesarean section has 
been performed. 

After removal of the child the uterus is drawn out 
through the abdominal wound, and the ecraseur applied 
below the ovaries and the lower end of the uterine incis- 
ion; the ecraseur having been tightened so that all 
hemorrhage is checked, the uterus with its appendages 
is cut away about an inch above the loop. 

The stump should be kept outside the abdominal 
wound, the clamp and transfixion pins resting upon 
the surface on each side of the incision. 

The usual antiseptic precautions must be used. 

3. PORRO-MULLER OPERATION.— A modifica- 
tion of the Porro operation in order to prevent hemor- 
rhage from the divided uterine tissue. The abdominal 
incision must be made sufficiently large for the entire 



ABDOMINAL SECTION. 183 

uterine mass with its contents to be brought outside ; 
the lower part of the uterus is then constricted and the 
child extracted. 

The great length of the abdominal incision, and the 
difficulty of bringing the uterus outside, are thought by 
some to increase rather than diminish the risks of the 
operation. 

4. LAPARO-ELYTROTOMY.— A substitute for the 
preceding operations, by means of which the opening 
of the peritoneal cavity and incision of the uterus are 
avoided. 

The os having been sufficiently dilated for the child 
to be drawn through the cervix, the operation is com- 
menced by making an incision parallel to Poupart's 
ligament and about six inches in length, the line of the 
incision extending from a point about one and a half 
inches above and to the outside of the pubis to another 
point about one inch above the anterior superior spine 
of the ilium. The right side is the one usually chosen 
for the operation, although it can be done on the left. 

By drawing the uterus to the side opposite that 
selected for the operation the tissues are put on the 
stretch, and on this account are more easily dissected. 

When the peritoneum has been reached it must be 
carefully separated from the adjacent tissues, and lifted 
up that the vaginal wall may be brought into view. 

A small transverse incision having been made through 
the vagina, both index fingers are inserted and the open- 
ing enlarged to the necessary extent by tearing the tis- 
sues that hemorrhage may be avoided. 

The cervix is then drawn into the opening thus made 
in the vagina, and the os being well dilated, and the 



184 OBSTETRIC SYNOPSIS. 

membranes ruptured, the child may be extracted by 
simple traction, b}^ means of the forceps, or by version. 
This operation, although more difficult than the pre- 
ceding ones, if skillfully performed should increase the 
mother's chances of recover}'. 



APPENDIX. 



UNIFORMITY IN OBSTETRICAL NOMENCLATURE. 

The report as accepted by the Obstetric Section of 
the Ninth International Medical Congress, held in Wash- 
ington, D. C, September, 1887. 

A. It is desirable to try to attain to uniformity in 

obstetrical nomenclature. 

B. It is possible to arrive at uniformity of expression 
in regard to: 1st. The Pelvic Diameters; 2d. The Di- 
ameters of the Fcetal Head ; 3d. The Presentations of 
the Foetus ; 4th. The Positions of the Foetus ; 5th. The 
Stages of Labor ; 6th. The Factors of Labor. 

C. The following definitions and designations are 
worthy of general adoption by obstetric teachers and 
authors : — 

I. PELVIC BRIM DIAMETERS. 

1. Ant ero -Posterior. (1) Between the middle of the 

sacral promontory and the point in the upper border 
of the symphysis pubis crossed by the linea-terminalis 
= Diameter Conjugate Vera, C. V. (2) Between the 
middle of the promontory of the sacrum and the lower 
border of the symphysis pubis = Diameter Conjugate 
Diagonalis, Cd. 

2. Transverse. Between the most distant points in the 

right and left ileo-pectineal lines = Diameter Trans- 
versa, T. 

3. First Oblique. Between right sacro-iliac synchondro- 

sis and left pectineal eminence = Diameter Diagonalis 
Dextra, D. D. 

16* (185) 



186 APPENDIX. 

4. Second Oblique. Between left sacro-iliac synchon- 
drosis and right pectineal eminence = Diameter Diag- 
onalis Lceva, D. L. 

II. FCETAL HEAD DIAMETERS. 

1. From the tip of the occipital bone to the centre of the 

lower margin of the chin = Diameter Occipito-Men- 
talis, O. M. 

2. From the occipital protuberance to the root of the nose 

= Diameter Occipito ^-Frontalis, O. F. 

3. From the point of union of the neck and occiput to the 

centre of the anterior fontanelle = Diameter Sub- Oc- 
cipito -Br egmatica, S. O. B. 

4. Between the two parietal protuberances = Diameter Bi- 

Parietalis, Bi-P. 

5. Between the two lower extremities of the coronal suture 

= Diameter Bi- Temporalis, Bi-T. 

HI. PRESENTATION OF THE FCETUS. 

The presenting part is the part which is touched by 
the finger through the vaginal canal, or which, during 
labor, is bounded by the girdle of resistance. 

The occiput is the portion of the head lying behind 
the posterior fontanelle. 

The sinciput is the portion of the head lying in front 
of the bregma (or anterior fontanelle). 

The vertex is the portion of the head lying between 
the fontanelles and extending laterally to the parietal 
protuberances. 

Three groups of presentations are to be recognized, 
two of which have the long axis of the foetus in cor- 
respondence with the long axis of the uterus, while in 
the third the long axis of the foetus is more oblique or 
transverse to the uterine axis. 

1. Longitudinal. (1) Cephalic, including vertex and its 

modifications ; face and its modifications ; (2) Pelvic, 
including breech and feet. 

2. Transverse or trunk, including shoulder, or arm and 

other rarer presentations. 



APPENDIX. 187 

IV. POSITIONS OF THE FCETUS. 

The positions of the foetus are best named topo- 
graphically, according as the denominator looks — first, 
to the left or right side, and second, anteriorly or pos- 
teriorly. When initial letters are employed it is desir- 
able to use the initials of the Latin words. 

In the case of vertex positions we have : — 
Left Occipitoanterior = Occipito-Lma Anterior, O. L.A. 
Left Occipito-Posterior = Occipito-Lceva Posterior, O.L.P. 
Bight Occipito-Posterior = Occipito-D extra Posterior, 

O. D. P. 
Bight Occipito -Anterior — Occipito-D extra Anterior 

O. D. A. 

The face positions are : — 
' Bight Mento -Posterior ■= Mento-B ] extra Posterior, M. D.P. 
Bight Mento- Anterior = Mento-Dextra Anterior, M. D. A. 
Left Mento- Anterior = Mento-Lwva Anterior, M. L. A. 
Left Mento -Posterior = Mento-Lmva Posterior, M. L. P. 

The pelvic positions are : — 

Left Sacro- Anterior = Sacro-Lceva Anterior, S. L. A. 
Left Sacro -Posterior = Sacro-Lwva Posterior, S. L. P. 
Bight Sacro -Posterior = Sacro-Dextra Posterior, S. D. P, 
Bight Sacro -Anterior = Sacro-Dextra Anterior, S. D. A. 

The shoulder presentations are (left and right side of the 
mother) : — 

Left Scapula- Anterior = Scapula-Laiv a Anterior, Sc. L. A. 
Left Scapula-Posterior =Scapula-Lceva Posterior, Sc. L. P. 
Bight Scapula-Posterior = Scapula-D extra Posterior, 

Sc. D. P. 
Bight Scapula- Anterior = Scapula- D extra Anterior, 

Sc. D. A. 



188 APPENDIX. 

V. THE STAGES OF LABOR. 

Labor is divisible into three stages : — 

1. First Stage. From the commencement of regular 

pains till complete dilatation of the os externum = 
Stage of Effacement and Dilatation. 

2. Second Stage. From dilatation of os externum till 

complete extrusion of child = Stage of Expulsion. 

3. Third Stage. From expulsion of child to complete 

extrusion of placenta and membranes = Stage of the 
After-birth. 

VI. THE FACTORS OF LABOR ARE : (1) The Powers. 
(2) The Passages. (3) The Passengers. 
{Signed) De Laskie Miller, M.D., 

President of the Section. 
A. F. A. King, M.D., 
William T. Lusk, M.D., 
A. R. Simpson, M.D. 



INDEX. 



PAGE 

Abdomen, anatomy of 1 

appearance of in pregnancy 52 

enlargement of in pregnancy 56, 58 

Abdominal bandage 100 

pregnancy 61 

section 180 

Abnormalities of the sexual organs 103 

Abnormal labor 101 

pregnancy 60 

Abortion 73, 159 

Acetabulum 3 

Accidental hemorrhage 124 

Affections of circulatory organs in pregnancy 67 

of respiratory organs in pregnancy . 67 

After-birth 82 

pains 82, 136, 138 

Albuminuria 54, 64 

Allantois 37 

Amnii, liquor 39 

Amnion 38 

Anaemia in pregnancy 63 

Anaesthetics in labor 100 

Anatomy of the abdomen 1 

of the breasts 2 

of the external genital organs 10 

of the internal genital organs 13 

of the pelvis 3 

Anodynes in labor 100 

Anomalies of the pelvis 105 

of the uterus 18 

Anteflexion of gravid uterus 67 

Anteversion of gravid uterus 67 

Appendix 185 

Arbor vitae 18 

Area germinativa 36 

pellucida 36 

Areola of breast 3, 52 

(189) 



190 INDEX. 

PAGE 

Arm, dorsal displacement of 112 

presentation of 91, 92 

Articulations of pelvis 3 

Artificial abortion 159 

feeding of infants , . . . . 144 

Ascites, diagnosis of from pregnancy 58 

Asphyxia neonatorum 141 

Atresia of the generative tract 103 

Axis of pelvis 6 

traction forceps (Simpson's) 163 

Ballottement 57 

Bandage, abdominal 100 

Barnes' dilators 124, 161 

Bartholin, glands of 9 

Battledore placenta 44 

Bed, preparation of in labor 93 

Binder, abdominal 100 

Bi-polar version 171, 173 

Blastodermic membrane 33, 35 

Blood, alterations of in pregnancy 53 

and circulatory system, disorders of in pregnancy .... 63 

supply of ovary 22 

supply of pudendum 13 

supply of uterus . 20 

supply of vagina 15 

Blunt hook 179 

Bones of pelvis 3 

Breasts, anatomy of 2 

appearance of in pregnancy 52 

areola of , 3 

care of 146 

inflammation of 147 

Breech presentation . . 89 

Bregma (anterior fontanelle) 47 

Broad ligaments 19 

Bromide of ethyl, use in labor 101 

Brow presentation 88, 110 

Bulbi vaginae 9 

Bulbo-cavernosi 8 

Bulb of ovary 23 

Caesarian section 181 

Canals of Miiller 19 

Caput succedaneum \ 141 

Carcinoma uteri in pregnancy 69 



INDEX. 191 

PAGE 

Cardiac diseases in pregnancy 69 

Carunculae myrtiformes 12 

Catheter, introduction of 12 

use of in asphyxia neonatorum 142 

use of in prolapse of the umbilical cord 114 

Caul 81 

Causes of labor 77 

Cavity of pelvis 4 

of uterus 16 

Cellulitis, pelvic 152 

Cephalic version 171 

Cephalotribe 178 

Cervix uteri, arbor vitas of 18 

atresia of 103 

cavity of 16 

changes of in pregnancy 56 

laceration of 132 

mucous membrane of 18 

rigidity of . 104 

shortening of 56, 80 

Changes in pregnancy, maternal 51 

Childbed, management of 138 

pathology of 145 

# physiology of 135 

Chloral, use of in labor 101 

use of in eclampsia 121 

Chloroform, use of in labor 100 

Chorea in pregnancy 67 

Chorion, primative 31,39 

true 39 

Circulation of foetus 48 

Clitoris . . . . 12 

Climate, influence of on menstruation 27 

Cocaine, use of in labor . . 101 

Coccyx 3 

Coccygeus muscle 7 

Colostrum 137 

Columns of vagina 14 

Commissures, anterior 11 

posterior 11 

Complicated labor 118 

presentations 112 

Concealed hemorrhage 124, 126 

Conception 30 

Condition and care of infant 140 

Confinement, prediction of date of 59 



1 92 INDEX. 

PAGE 

Congestive hypertrophy of uterus, diagnosis of from pregnancy . 58 
Conjugate diameters of pelvis, external 5, 107 

true . 107 

Constipation in pregnancy 63 

Continued fevers in pregnancy 68 

Contracted pelvis 106 

Contractions of abdominal muscles in labor 79 

of uterus in labor 78 

Convulsions, puerperal (eclampsia) 65, 119 

Cord, umbilical 43 

Corpus luteum 26 

Cranioclast 179 

Craniotomy 176 

forceps 178 

Cranium, changes in pregnancy 53 

Crede's method of removing placenta 99 

Crotchet 179 

Cul-de-sac of Douglas 13,17 

Cystic tumor of ovary, diagnosis of from pregnancy 59 



Death of foetus 72, 118 

Decapitation 179 

Decidua 34 

Deficiency of milk 146 

of uterine force in labor 102 

Development of foetus 44 

of ovum 32 

Diabetes in pregnancy 65 

Diagnosis of pregnancy 55 

Diameters of foetal skull 47 

of pelvis 5, 185 

Diarrhoea in pregnancy 63 

Digestive system, changes in pregnancy 53 

disorders of in pregnancy 62 

Discus proligerus 24 

Diseases of pregnancy 68 

Disorders of lactation 145 

of pregnancy 62 

Displacements of uterus in pregnancy 67 

Double uterus 18 

Douglas' cul-de-sac 13, 17 

Ductus arteriosus 50 

venosus 48 

Duration of labor 82 

of pregnancy 59 



INDEX. 193 

PAGE 

Eclampsia (puerperal convulsions) 65, 119 

Elbow presentation 91 

Embolism, puerperal 154 

Embryotomy 175 

Endometritis in pregnancy 70 

Epiblast 35 

Episeotomy 97 

Erector clitoridis 8 

Ether, use of in labor 100 

Ethyl bromide, use of in labor 101 

Eruptive fevers in pregnancy 68 

Eustachian valve 50 

Evisceration 180 

Examination of patient 94 

Excess of milk (galactorrhea) 145 

of uterine force in labor , 101 

External genital organs, anatomy of 10 

Extra-uterine pregnancy : 61, 117 

Face presentation 86, 110 

Factors of labor 188 

Fallopian tubes 21 

False pains 80 

Fibroid tumor of uterus, diagnosis of from pregnancy 58 

Fillet 169 

Fimbriae of Fallopian tubes 21 

First stage of labor 80, 95 

Fissures of nipples 146 

Foetal causes of abnormal labor 109 

head, diameters of 47, 186 

Foetus, circulation of 48 

death of 72, 118 

development of 44 

heart sounds of . . . 57 

movements of 57 

position of 48 

Fontanelles « 47 

Foot presentation 90 

Foramen ovale 50 

Forceps, obstetric. Parvin-Davis 162 

Simpson's axis traction 163 

Tarnier's 163 

use of 161 

Wallace 162 

W.S.Stewart's 167 

Fossa navicularis 12 



194 INDEX. 

PAGE 

Fourchette 11 

Fundus of uterus 16 



Galactophorous ducts 2 

Galactorrhea 145 

Gastro-elytrotomy 181 

hysterectomy 181 

hysterotomy 181 

Genital organs, anatomy of external 10 

anatomy of internal 13 

Genito-urinary system, disorders of in pregnancy 64 

Germinal spot 24 

vesicle 24 

Glands, mammary 2 

of Bartholin (vulvo-vaginal) 9 

of cervix 18 

of vulva 12 

utricular 17 

vulvo-vaginal (Bartholin) 9 

Graafian follicle (ovisac) 23 

Gravid uterus, displacements of 67 

measurements of 15 



Haemetometra (retained menses), diagnosis of from pregnancy . 58 

Hand presentation 91 

Head presentation 83 

Heart, hypertrophy of in pregnancy 53 

sounds of foetus 57 

Hemorrhage, accidental 124 

after delivery (post-partum) 125 

before delivery 124 

concealed 124, 126 

Haemorrhoids in pregnancy 63 

Hook, blunt 179 

Hour-glass contraction of uterus 128 

Hydatidiform mole (vesicular mole) 70 

Hydraemia in pregnancy 63 

Hydramnion (polyhydramnios) 71 

Hydrocephalus 115 

Hydroperione 35 

Hvdrorrhcea gravidarum 70 

Hymen 12 

Hypoblast = 36 

Hysteria in pregnancy 53, 59 



INDEX. 195 

PAGE 

Ilio-pectineal line 4 

Ilium 3 

Impregnation 31 

Indications for abdominal section 180 

for artificial abortion 159 

for embryotomy 175 

for use of forceps 164 

for version 171 

Induction of abortion 159 

of premature labor 160 

Infant, condition and care of 140 

Inflammation of breast 147 

Inlet of pelvis 5 

Insanity, puerperal 157 

Intercurrent diseases in pregnancy 68 

Intermittent uterine contractions in pregnancy 57 

Internal genital organs, anatomy of . 13 

Intra-uterine amputations 72 

Inversion of uterus 129 

Irritability of bladder in pregnancy 65 

Ischium 3 

Jaundice in new-born child . 142 

in pregnancy 69 

Jelly of Wharton 44 

Joints, changes in pregnancy 4 

Knee presentation , . 90 

Knots in umbilical cord , . , 44 

Kyestine 54 

Kyphosis 107 

Labia majora 11 

minora (nymphse) 11 

Labor, abnormal 101 

causes of 77 

complicated 118 

duration of 82 

management of normal 92 

mechanism of 83 

muscular mechanism of 78 

pains of 79 

phenomena of 77 

premature 73, 160 

stages of 79 



196 INDEX. 

PAGE 

Laceration of cervix 132 

of perineum ' 133 

of vagina 132 

of vulva 133 

Lactation 143 

Lactiferous ducts (galactophorous) 2 

Lamina dorsales 36 

Lamination 179 

Lanugo . , 45 

Laparo-elytrotomy 183 

Lateral obliquity of foetal head 110 

of uterus 52 

Leucorrhcea in pregnancy 66 

Levator am muscle 7 

Ligaments, broad 19 

of ovaries 22 

of uterus 19 

Ligation of umbilical cord 98, 140 

Liquor amnii 39 

folliculi 24 

Lochia 136 

Locking of obstetric forceps 168 

Lordosis 107 

Lying-in period . , 145 

Male element of generation (spermatozoid) 30 

Malpresentations 109 

Mammary changes in pregnancy 56 

gland 2 

Management of childbed 138 

of normal labor 92 

Maternal causes of abnormal labor 101 

changes in pregnancy 51 

Measurements of false pelvis 5, 107 

of true pelvis , 5, 107 

of uterus 15 

Mechanism of labor 83 

Meconium 137,141 

Membrana granulosa 24 

Menopause 28 

Menstruation 27, 55 

Mesoblast : . 36 

Milk, deficiency of 146 

excess of * 145 

fever =138 

leg 156 



INDEX. 197 

PAGE 

Miscarriage 73 

Missed labor 73 

Mole pregnancy, fleshy 73 

hydatidiform (vesicular) 70, 72 

Mons venersis 10 

Monstrosities 115 

Montgomery, tubercles of 3, 52 

Morning sickness in pregnancy 53, 55 

Morphia in labor 101 

Movements of foetus 57 

Mucous membrane of uterus 17 

of vagina 14 

Miiller, canals of 19 

Multiple pregnancy 60, 116 

Mummification 73 

Muriform body . . 33 

Muscular mechanism of labor 78 

Naegele, obliquity of foetal head 110 

Nausea in pregnancy 53. 62 

Neck of uterus (cervix) 16 

Nerves of ovary 23 

of pudendum 13 

of uterus 21 

of vagina 15 

Nervous system, changes in, in. pregnancy 53 

disorders of in pregnancy 55 

Neuralgise in pregnancy QQ 

Nipples, sore 146 

Normal labor, management of 92 

Nurse, wet 143 

Nymphse (labia minora) 11 

Obliquity of foetal head (Naegele) 110 

of uterus, right lateral 52 

Obstetric forceps 161 

nomenclature 185 

operations 159 

Occipito-posterior positions 109 

(Edema in pregnancy 64 

Osinnominatum 3 

uteri 16 

Osteophyte 53 

Ovarian pregnancy 61 

tumor, diagnosis of from pregnancy 59 

Ovaries 22 



198 INDEX. 

PAGE 

Oviduct (Fallopian tube) 21 

Ovisac (Graafian follicle) 23 

Ovula Nabothii 18 

Ovulation 25 

Ovule or Ovum 24, 30 

Pains, after 82, 136, 138 

false 80 

of labor 79 

Pampiniform plexus 20 

Paralyses in pregnancy , 66 

Parovarium 19 

Pathology of childbed 145 

of decidua, ovum, and foetus 70 

Pelvic cellulitis and peritonitis 152 

brim diameters ... 185 

presentation 89, 111 

Pelvis, anatomy of 3 

anomalies of 105 

articulations of 3 

axis of 6 

bones of 3 

cavity of 4 

changes in, in pregnancy 51 

contents ■ 7 

differences in, in the sexes «... 6 

floor of 7 

measurements of 5 

planes of 6 

Perineal body 9 

Perineum, anatomy of 13 

care of in labor • 97 

laceration of 133 

rigidity of 104 

Peritonitis, pelvic 152 

Phenomena of labor .... 77 

Phlegmasia alba dolens (milk-leg) 156 

Physiology 25 

Pigmentary changes in pregnancy 56 

Placenta, anatomy of , 41 

battledore 44 

diseases of 70 

expression of 99, 129 

prsevia 121 

removal of 129 

retention of 128 



INDEX. 199 

PAGE 

Planes of pelvis 6 

Podalic version 172 

Polar globule 31 

Polyhydramnios (hydramnion) 71 

Porro-Muller operation 182 

Porro's operation 182 

Position of foetus 48 

Position of patient in labor 93 

Post-partum hemorrhage 125 

Pregnancy, abnormal 60 

diagnosis of . . . ■ 55 

differential diagnosis of 58 

diseases of 68 

disorders of 62 

duration of 59 

extra-uterine 61,117 

multiple 60, 116 

signs of 55 

spurious 59 

Premature labor 73, 160 

Presentation of foetus 186 

of head 83 

of pelvis 89,111 

of trunk 91,112 

Primitive chorion 31 

trace 36 

Procidentia of uterus in pregnancy 67 

Prolapse of umbilical cord 113 

of uterus in pregnancy 67 

Pruritus vulvae in pregnancy QQ 

Ptvalism in pregnancy 53, 63 

Puberty 25 

Pubis 3 

Pudendum 10 

Puerperal convulsions (eclampsia) 65, 119 

fever (septicaemia) 148 

insanity 157 

state 135 

thrombosis and embolism 154 

Pulmonary diseases in pregnancy 69 

Pulse in labor 135 

Quickening 51, 56, 60 

Race, influence of on menstruation 27 

Rectal triangle 9 



200 



INDEX. 



^ PAGE 

Retention of placenta 1266 

Retroflexion of gravid uterus 7 

Retroversion of gravid uterus . . . . 67 

Rigidity of the cervix in labor 104 

Rigidity of the perineum in labor 104 

Ruptures and lacerations of the genital canal 130 

Rugse of the vagina 15 

Sacrum 3 

Salivation in pregnancy 53, 63 

Scoliosis 107 

Secondary hemorrhage 125, 128 

Second stage of labor 81, 96 

Segmentation of yelk 32 

Septicaemia, puerperal 148 

Sex, prediction of 57 

Shortening of cervix 56. 80 

Shoulder presentation 91, 112 

Signs of pregnancy 55 

Somatopleure 36 

Sore nipples 146 

Souffle, umbilical 58 

uterine 57 

Spermatozoid 30 

Splanchnopleure 36 

Sphincter ani muscle 9 

Spurious pregnancy 59 

Stages of labor 79, 187 

Stroma of ovary 22 

Sugar in urine in pregnancy 54, 65 

Superfecundation 61 

Superfcetation 61 

Surroundings, influence of on menstruation 27 

Sutures of foetal skull 46 

Syphilis in pregnancy 69 

Temperature in labor 135 

Third stage of labor 82, 98 

Thrombosis, puerperal 154 

Thrombus of vagina and vulva 133 

Torsion of umbilical cord 44, 75 

Traction on umbilical cord 99, 129 

with obstetric forceps , 168 

Transverse presentation 91,112 

Transversus perinei muscle 9 

Trunk presentation 91, 112 



INDEX. 201 

PAGE 

Tubal pregnancy 61 

Tubercles of Montgomery 3, 52 

Tubo-ovarian ligament 21, 22, 31 

Tumors obstructing labor 105 

Turning (version) 170 

Twin pregnancy 60, 116 

Umbilical cord 43 

cord, prolapse of 113 

vesicle (yelk-sac) 37 

Ursemia (urinsemia) in eclampsia . . . 119 

Urethral triangle . . . 8 

Use of obstetric forceps 161 

Urine, changes in, in pregnancy 53 

Uterine contractions 78 

inertia . 102 

tumor, diagnosis of, from pregnancy 58 

Uterus, anatomy of 15 

anomalies of 18 

cavity of 16 

differences in virgin and multipara 18 

displacements of 67 

ligaments of 19 

inversion of ( 129 

measurements of 15 

regions of 16 

rupture of 130 

structure of 16 

Utricular glands 17 

Vagina, anatomy of 13 

columns of 14 

laceration of . . , 132 

orifice of 12 

Varicose veins in pregnancy 64 

Vectis 169 

Vernix caseosa 45, 141 

Version 170 

Vertex presentation 83 

Vesicular mole 70 

Vestibule 12 

Viability 46 

Villi of chorion 40 

Vitelline duct , . 37 

Vitelline membrane 24 

Vitelline nucleus , , 32 



202 INDEX. 

PAGE 

Vitellus (yelk) 24 

Vitriform body (corps reticule) 41 

Vomiting in pregnancy 53, 62 

Vulva . 11 

Vulvo-vaginal glands (glands of Bartholin) 9 

Wet-nurse 143 

Weight of foetus 46 

Wharton's jelly 44 

Wolffian bodies 19, 45 

Yelk (vitellus) . . , 24 

Yelk-sac (umbilical vesicle) 37 

Zona pellucida 24 




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